
Class 
Book 



COPYRIGHT DEPOSIT 



GUNSHOT INJURIES 



HOW THEY ARE INFLICTED 
THEIR COMPLICATIONS AND TREATMENT 



BY 

COLONEL LOUIS A. LA GARDE 

M 
UNITED STATES ARMY MEDICAL CORPS (Retired) 

LATE COMMANDANT AND PROFESSOR OF MILITARY SURGERY, U. S. ARMY 

MEDICAL SCHOOL; PROFESSOR OF MILITARY SURGERY, MEDICAL 

DEPARTMENT, N. Y. UNIVERSITY, ETC., ETC. 



SECOND, REVISED EDITION 



Prepared under the Direction of the Surgeon 

General United States Army and Published 

by Authority of the Secretary of War 



NEW YORK 

WILLIAM WOOD AND COMPANY. 

MDCCCCXVI 




\0y 



\<0 



Copyright, 1916, 
By WILLIAM WOOD AND COMPANY 



& 



DEC -7 1916 







THE. MAPLE. PRESS. YORK. PA 



, CI,A446736 



(9(000 



PREFACE TO SECOND EDITION 

In the short interval of two and a half years which has elapsed 
since the preparation of the first edition of this book a large amount of 
new material has been added to the literature of gunshot injuries as 
a result of the present European War. In consequence thereof any 
work on gunshot injuries no matter how recently produced requires 
extensive additions This was realized and the labor of revision was 
begun shortly after war was declared. 

The additions that have been made in the present edition refer to 
the u'3e of certain types of machine guns and the method of fire from 
these weapons; the use of the high explosive shell and shrapnel in the 
"77" and "75" mobile artillery of the French and German armies; 
the composition of the compound rifle bullet of the British army and 
how it has operated to provoke anew the discussion on Dumdum 
bullets. Chapter IV, on Infection of Gunshot Wounds, has been 
rearranged, and most of it rewritten. This was rendered necessary * 
because of the valuable contributions which the bacteriologists have 
made on the invasion of the fecal anaerobes in the wounds of the 
present war. Chapter V, which takes up the subject of the General 
Treatment of Gunshot Wounds, has also been rearranged and largely 
rewritten on account of the radical departures which have been 
made in the treatment of infected wounds, by Sir A. E. Wright, 
Alexis Carrel, Colonel H. M. W. Gray and others. To Chapter VI 
we have added material of much value on the subject of Injuries of the 
Superior Longitudinal Sinus, a traumatism which has developed largely 
as a result of tangential shots which have developed from the high 
velocity of the military rifle and machine gun. Material additions 
have been made on the subject of Chest Wounds in Chapter VIII. 
Hemothorax has been more frequent and more difficult to treat in the 
present war as a result of severe wounds from close fire by the rifle, 
and the numerous hits by shrapnel and high explosive shell fragments. 
In Chapter IX, devoted to Gunshot Wounds of the Abdomen, the 
views of military surgeons on the value of early operation have been 
discussed at length. Important additions have been made to Chap- 
ter X, in that part of it devoted to the management of all kinds 

iii 



IV PREFACE 

of aneurysms. The value of vessel suture over the old-time method 
of ligation is dealt with in accordance with the views of a number of 
well known writers on the subject. In Chapter XII, on the Gunshot 
Injuries of the Diaphyses of the Long Bones, we have embodied at 
length the new treatment of Septic Gunshot Fractures by the hyper- 
tonic saline solutions and hypochlorous acid methods. 

A new chapter has been added on the Casualties of Battles, 
which contains besides the usual statistics well known to military 
writers, such data as are available from estimates of losses in the 
present war. We have to state, however, that the figures are approx- 
imate only, though we hope they may be sufficiently accurate for 
comparative purposes. The difficulty of obtaining information on 
battle casualties during a war is well known. The reasons are ob- 
vious. The state is often uninformed on the subject, and besides this, 
the combatants often hesitate to make known battle losses for mili- 
tary reasons. Our data have come from official reports, the censored 
figures of attaches, magazine writers, etc. Until the end of the con- 
flict, when the well organized governments have had time to compile 
their figures, we cannot expect anything of a more definite nature on 
battle casualties from the great World War. 

L. A. L. 

2624 Woodley Place, 
Washington, D. C. 
October 3, 1916. 



PREFACE TO FIRST EDITION 

The necessity for a book on Gunshot Injuries for the use of the 
military services and the American surgical profession was not appar- 
ent until very recently. After the conclusion of our great Civil War 
the volumes of Otis 1 supplied all the wants of the profession in this 
particular branch of surgery. The matter in the volumes referred to 
was rich in variety and so well suited to the requirements of the 
clinician and students of surgical literature that it became the refer- 
ence work of the medical profession the world over. But the subject 
of Gunshot Injuries as a whole has been so modified by radical changes 
in the armament of the nations and the results in wounds by firearms 
have been so modified by modern methods of treatment, that the works 
of Otis and his contemporaries have now been entirely superseded as 
far as practical surgery is concerned. 

The demand of the military and civil surgeon now requires a presen- 
tation of the important subject of gunshot injuries as inflicted by a 
new armament, and treated after the methods of modern surgical prac- 
tice. The characteristic features of the wounds by the former, and the 
results attained in them by the latter have entirely revolutionized 
military surgery, so that the wounds by firearms of fifty years ago and 
the results of the treatment then in vogue form no guide for a study of 
the subject to-day. 

Some authors on military surgery have sought from the time fire- 
arms were first used to treat gunshot injuries in war, as a specialty in 
surgery, apart from the class of gunshot wounds the civil practitioner 
is called upon to treat in civil practice. A careful study of the subject 
will show that there has been but little difference in the character 
of the large majority of the wounds from these sources. Wounds ob- 
served in the two conditions mentioned have for the most part been 
caused by similar weapons. In the evolution of firearms the rifle of 
the sportsman has differed but little from the military rifle, and the 
same may be said of pistols and revolvers, except that in civil prac- 
tice wounds were more often inflicted by bullets having less weight 
and caliber, possessed with lower velocity, and animated by less 

1 Medical and Surgical History of the War of the Rebellion, Parts I, II, and 
III, Surgical Vols., by Geo. A. Otis, Surg., IT. S. A. 

V 



VI PREFACE 

energy. This does not apply to the days of the code duello, because 
then the weapon used in personal combat was, ballistically speaking, 
similar to the military hand weapon of that day and the character 
of the wounds inflicted in military and civil practice was the same. 

In our day reduced caliber rifles employing steel mantle projec- 
tiles used by armies and the sporting world alike, serve to maintain 
the similarity in wounds seen by the military and civil surgeon, and 
since the automatic hand weapons of the pistol and revolver class 
using steel mantle projectiles are coming into use in the civil popula- 
tion and the military services, the similarity of the wounds seen in 
peace and war will be further emphasized. 

In recent wars the use of hand grenades, bombs and other devices 
which are made to burst by the agency of high explosives is becoming 
common, but the civil practitioner has opportunities to see the lacer- 
ated wounds from nitroglycerin and all of its modifications now ex- 
tensively used in engineering projects everywhere so that the charac- 
ter of these wounds is not peculiar to the military service. 

The difference in environment has probably done more than any 
other one thing to cause the earlier military surgeons to regard gun- 
shot injuries in war as a special branch of surgery, and that came 
largely from the fact that military surgery is mostly made up of 
emergency surgery. But during these industrial times the practice 
of the civil surgeon is to a large extent made up of emergency surgery, 
and like his confreres in military practice he is well versed in all the 
resources of first-aid to the injured. 

In great wars the military surgeon has exceptional opportunities 
to observe gunshot wounds of all kinds. Here again we find that 
gunshot inj uries form a branch of surgery common to the military and 
civil surgeon because armies are never provided with sufficient relief 
personnel in peace to meet all the exigencies in war. As example we 
find that the civilian surgeons out-numbered the regular medical of- 
ficers in the Spanish- American in the ratio of 6 to 1, and in the great 
Civil War 66 to 1. When war is declared assistance has to come from 
the medical gentlemen in civil life and history shows that their services 
are more than welcome, and that they have always responded most 
willingly to their country's call in times of stress. 

In the following chapters the author has as far as possible pre- 
sented the characteristic features of wounds by the old armament in 
preantiseptic times, and compared these with the results of gunshot 
injuries by modern arms in the Spanish- American, Anglo-Boer, 



PREFACE 



Vll 



Russo-Japanese and Turko-Balkan Wars. He has also availed himself 
of the character of wounds by firearms in civil life and their results as 
compared to similar wounds in the military service. Like observations 
have also been made to a less extent on wounds by different kinds of 
rifles, pistols and revolvers on animals, experimentally and in the hunt. 

There is a medico-legal aspect involved in the subject of gunshot 
injuries that is not treated as a rule in books on military surgery, but 
we know that the military surgeon is often called into courts to 
testify in cases having a medico-legal bearing and that it would appear 
to be his duty as much as that of the civil surgeon to acquaint himself 
with this part of the subject, hence the chapter on The Medico-legal 
Phases of Gunshot Wounds. 

The bulk of the matter in the following chapters has been culled 
from lectures which for more than twelve years have formed the basis 
for teaching in civil and military medical schools — the method of 
teaching in the one has differed but little from that employed in the 
other. 

The chapter on Field X-ray Apparatus has been confined to a 
discussion of types of apparatus which have been found most suitable 
for field work. We believe that good radiography can only be done 
by trained radiographers; especially is this so under the unfavorable 
conditions which obtain during active service and for this reason all 
description of radiographic technique has been omitted from this 
work. For the entire rendition of this chapter we are indebted to 
Captains Henry F. Pipes, W. A. Duncan and Arthur C. Christie, 
Medical Corps, U. S. Army. 

The first chapter was revised in the office of the Chief of Ordnance 
and the part of the chapter on Ballistics was written in that office 
under the supervision of Colonel John T. Thompson, O. D., U. S. 
Army. 

The remaining chapters were revised in the office of the Surgeon 
General by Lt. Col. F. A. Winter, M. C, U. S. A., to whom I am in- 
debted for valuable assistance. 

L. A. L. 
Washington, January 1, 1914. 



CONTENTS 

CHAPTER I 

Technical Considerations 



Page 



1. Definition of a Gunshot Wound. 2. Firearms. 3. Explosives. 

4. Projectiles. 5. Ballistics 1-33 

CHAPTER II 

Characteristic Lesions Caused by Projectiles 

1. Wounds by Military Rifles in Recent Wars. 2. Dumdum bullet con- 
troversy in present European War. 3. Effects of the Pointed, 
Spitz, or Bullet "S" on Cadavers, Large Animals, and in the Turko- 
Balkan War. 4. The Stopping Power or Shock Effects of Bullets 
from Rifles, Pistols and Revolvers. 5. Explosive Effects of Rifle 
Bullets Explained. 6. Wounds by Projectiles from the Artillery 
Arms. 7. Wounds from Pistols, Revolvers, Shotguns, and Target 
Rifles 34-115 

CHAPTER III 

Symptoms of Gunshot Wounds 
1. (a) Pain, (b) Shock, (c) Hemorrhage, and (d) Thirst. . 116-122 

CHAPTER IV 

Infection of Gunshot Wounds 

1. Infection of Gunshot Wounds. 2. Tetanus and Toy-pistol Tetanus. 

3. Poisoned Wounds 123-135 

CHAPTER V 

Treatment of Gunshot Wounds 

1. Arrest of Hemorrhage. 2. Treatment of Shock. 3. First Field 
Dressing. 4. Immobilization. 5. Administration of Food and 
Stimulants. 6. Treatment of Septic Wounds. 7. Antiseptics. 8. 
Hypochlorous Acid. 9. Eusol. 10. Eupad. 11. Treatment of 
Wounds by Saline Solutions. 12. Salt Sacs. 13. Open Treatment 
of Wounds. 14. Treatment by Excision and Primary Suture. 15. 
Treatment of Virulent Infections. 16. Tetanus and its Treatment. 

ix 



X CONTENTS 

Page 

17. Emphysematous Gangrene and its Treatment. 18. Exploration 
of Gunshot Wounds. 19. Treatment of Hemorrhage. 20. Remote 
Treatment of Wounds. 21. After Treatment of Wounds 136-164 

CHAPTER VI 
Gunshot Wounds of the Head, Face and Neck 

Head: 1. Wounds of the Scalp. 2. Wound of the Skull without Brain 
Lesion. 3. Fracture of the Outer Table. 4. Fracture of the Inner 
Table. 5. Fracture of the Skull with Brain Lesion. 6. Remote 
Effects in Head Wounds. 7. Hernia Cerebri. 8. Abscess of Brain. 
9. Treatment of Gunshot Fracture of the Cranium. 10. Operations 
upon Gunshot Wounds of the Head. 11. Lodged Missiles in Brain. 

Face: 1. Wounds of the Ear. 2. Wounds of the Orbit. 3. Wounds of 
the Nose. 4. Wounds of Malar Bones. 5. Wounds of the Upper 
Jaw. 6. Wounds of the Lower Jaw. 

Neck: 1. Wounds of the Neck without Injury to the Cervical Vertebrae, 
List of. 2. Complications in Wounds of the Neck. 3. Wounds of 
Blood-vessels. 4. Wounds of Nerves. 5. Wounds of the Air- 
passages 165-213 

CHAPTER VII 

Gunshot Wounds of the Spine 

1. Fatality of Different Regions in Wounds of the Spine. 2. Concussion 
of Cord by Large and Small Caliber Bullets. 3. Contusion of the 
Cord. 4. Hemorrhage of the Cord. 5. Treatment of Gunshot 
Injuries of the Spine 214-227 

CHAPTER VIII 

Gunshot Wounds of the Chest 

1. Non-penetrating. 2. Contusions. 3. Laceration and Penetration of 
the Chest Wall. 4. Humane Character of Gunshot Wounds of 
Chest by New Armament. 5. Symptoms and Complications. 6. 
Treatment of Gunshot Wounds of the Chest and their Treatment 
in the Present European War. 7. Wounds of the Chest with Frac- 
ture. 8. Wounds of Heart and Pericardium 228-244 

CHAPTER IX 

Gunshot Wounds of the Abdomen 

1. Contusions. 2. Non-penetrating Wounds. 3. Penetrating Wounds 
without Visceral Lesions. 4. Perforating Wounds with Visceral 
Lesions. 5. Statistics of Gunshot Injuries of Abdomen. 6. Treat- 



CONTENTS XI 

Page 

ment of Penetrating and Perforating Wounds, in Civil Hospitals 
and in Military Practice, Including the Present European War. 
7. Contraindications and Indications for Operation. 8. Wounds 
of the Small Intestine. 9. Wounds of the Stomach. 10. Wounds of 
the Large Intestine. 11. Wounds of the Sigmoid Flexure and 
Rectum. 12. Wounds of the Liver and Gall-bladder. 13. Wounds 
of the Pancreas. 14. Wounds of the Spleen. 15. Wounds of the 
Kidney. 16. Wounds of the Adrenal Gland. 17. Wounds of the 
Urinary Bladder. 18. Wounds of the External Genital Organs. 245-300 

CHAPTER X 

Injury to Peripheral Nerves — Injury to Blood-vessels and 

Nature op the Lesions 

1. Results of Injury to Blood-vessels. 2. Traumatic Aneurysms. 3. 
Aneurysmal Varix and Varicose (Arterio-venous) Aneurysm, and 
their Treatment in Recent Wars, Including the Present European 
War. 4. Injury to Peripheral Nerves 301-318 

CHAPTER XI 

Gunshot Wounds of Joints 

1. Humane Features of Joint Wounds by the New Armament. 2. 
Mortality from Wounds of Joints, in the last five Wars. 3. Wounds 
of Joints with Lodged Missiles. 4. Treatment of Wounds of Joints. 
5. Special Joints, Wounds of. 6. Special Reference to Gunshot 
Wounds of the Knee Joint and its Treatment as Recommended by 
Col. H. M. W. Gray in the Present European War 319-364 

CHAPTER XII 
Gunshot Injuries op the Diaphyses op the Long Bones 

1. Contusions. 2. Simple Fractures. 3. Compound Fractures. 4. Treat- 
ment of Gunshot Fractures of the Humerus. 5. Gunshot Frac- 
tures of the Forearm. 6. Wounds of the Hand. 7. Wounds of the 
Shaft of the Femur. 8. Fractures of the Tibia and Fibula. 9. 
Wounds of the Bones of the Foot 365-406 

CHAPTER XIII 
Casualties of Battle 

1. Table of Battle Losses by the Old and More Modern Implements of 
War. 2. Proportion of Killed to Wounded in Different Wars. 3. 
Influence of Modern Treatment on Losses in War. 4. Wounds 
by the Military Rifle and Artillery Fire. 5. Regional Distribution 



Xll CONTENTS 

Page 

of Wounds. 6. Gravity of Wounds by Different Weapons. 7. 
Regimental Losses. 8. Percentage of Casualties in the Wounded 
which Reach Hospital Care. 9. Casualties in the Present European 
War 407-424 

CHAPTER XIV 

Medico-legal Phases of Gunshot Wounds 

1. Diagnosis of a Wound Caused by Firearms. 2. At what Distance 
was the Firearm Discharged. 3. Was the Wound Inflicted before 
or after Death. 4. Is the Wound Dangerous to Life. 5. The 
Practitioner's Liability in Case of Infection. 6. How was the 
Wound Inflicted? 7. Was it Accident, Suicide or Homicide? 8. 
Identity of the Individual by the Flash of the Firearm. 9. Self- 
inflicted Non-fatal Wounds. 10. At what Time was the Firearm 
Discharged. 11. Was the Projectile Jacketed or not? 425-439 

CHAPTER XV 

Field X-ray Apparatus 

1. Importance of Radiography in Military Surgery. 2. The Particular 

Kind of Machine best Adapted to Field Work 440-448 



GUNSHOT WOUNDS 

CHAPTER I 

Technical Considerations 

1. Definition of a Gunshot Wound; 2. Firearms; 3. Explosives; 

4. Projectiles; 5. Ballistics 

1. DEFINITION 

The term gun has descended to us from those earlier days of the 
use of firearms when large guns like cannons, mortars, and the hand 
cannon carried by two men, were the only weapons used in war. 
Hand weapons like the musket, rifle, carbine, pistol and revolver were 
unknown until the lapse of several centuries, hence the phrase "gun- 
shot wounds, " which is now employed to designate the injuries caused 
by firearms. The surgical term — gunshot wound — has a wider 
application for the military surgeon than that usually understood by 
the surgeon in civil life. For the latter the term includes those wounds 
occurring in civil communities from missiles fired from portable 
firearms, viz.: weapons like shotguns, sporting rifles, pistols, revolvers, 
toy pistols, air-guns, etc. Such weapons propel missiles like bullets 
of varying caliber, lead pellets, powder grains, with and without wads, 
by means of a sudden explosive force resulting from the generation of 
large volumes of gases which are liberated by igniting explosive 
materials. 

Under the term gunshot wounds the military surgeon includes 
in his battle returns all wounds resulting from the effects of any 
explosive force. For instance, to him the wound caused from a splinter 
of wood detached by a fragment of shell is as much a gunshot wound as 
the injury which might have resulted from the shell fragment itself. 
The same may be said of the wounds that result from an explosion or 
any explosive contrivance of whatever kind such as a bomb, terrestrial 
mine, torpedo, or any engine or implement used in war. In medico- 
military parlance any missile that is set in motion with suffi- 
cient velocity by a sudden expansive force may cause a gunshot 
wound. 

1 



GUNSHOT WOUNDS 



2. FIREARMS 



For a proper estimate of the nature and character of gunshot in- 
juries as the subject appears in our literature, the surgeon should 
familiarize himself with the evolution of firearms, their projectiles, and 
the explosives which have been employed for the purpose of inflicting 
injuries from the earliest times. He should further have knowledge 
of the mechanics of projectiles as far as that part of the subject may 
relate to motion, velocity, and energy. 

In discussing firearms proper it is only necessary for our purpose to 
review briefly the evolution of weapons, giving the name and the 
salient features of each, reserving greater space for the more important 
subjects of projectiles, the mechanics of projectiles, etc. 

Firearms and Other Machines used in War. — Firearms of the 
military class are divided into those of the artillery and the so-called 
hand-weapons. Under the former will be included large guns, field 
guns, and other engines employed in war. 

Large Guns. — These are breech-loading rifled guns, the largest 
and heaviest types being used on large war vessels and in seacoast 
fortifications. The longest of these guns is about 50 feet, the weight 
about 130 tons and the caliber about 16 inches. They fire shot and 
shell, made from the hardest steel, weighing about 2400 pounds, 
with an initial velocity of about 2250 f.s. These large projectiles 
penetrate steel armor 21 inches in thickness at a distance of 5000 
yards. These heavy guns have various calibers down to 3 inches. 

Mobile Artillery and Siege Guns. — These vary in caliber from 3 
inches to 6 inches. The most common of the field guns is the 3-inch 
breech-loading steel rifle which accompanies an army in the field, 
while the heavy field or siege cannon, such as the 6-inch howitzer and 
4.7-inch gun, are used principally against fortified positions. All 
these types employ shell and shrapnel. 

Howitzers. — These are cannon of 3.8-inch, 4.7-inch and 6-inch 
caliber in our army, but shorter than the guns of the same calibers. 
They fire projectiles at lower velocities and at higher angles than guns. 

Mortars. — Are also cannon shorter than the guns or howitzers and are 
fired at lower velocities and with higher elevations than the latter. 
They are principally used to throw projectiles over fortified places or 
intervening obstacles into fortifications or bodies of troops which can- 
not be reached by ordinary gunfire, or upon the decks of vessels. 

Machine Guns. — This class of guns is used by all armies under 



FIREARMS 3 

different names. In our service we now employ the Automatic 
Machine Rifle, cal. 30 (Benet-Mercie system), which fires the infantry 
rifle ammunition at great speed. The gun used in our army fires 
approximately 700 shots per minute and its accuracy at 1000 yards 
is such that 85 per cent, of hits have been made against silhouettes on 
the target range, The wounds inflicted by the bullets of the machine- 
gun are the same in character as those produced by the rifle bullet. 
The armies engaged in the present European war use the Maxim 
rapid fire gun, or some modification of it. It has a single barrel 
which is kept cool by a water jacket or cooled by air radiation, and it is 
fired by constant pressure on the trigger. The gun in our service is 
easily folded for transportation, it weighs about 70 pounds. The ammu- 
nition is fed to the mechanism from a belt which carries 250 cartridges. 
In the present war abroad the machine gun is playing an increas- 
ingly important role. The fire is directed to meet conditions as they 
arise. In one instance the fire may be distributed, in an other it 
may be concentrated, or delivered obliquely. An "infilade fire" may 
be delivered on the flank of the enemy, and a " covering fire" is 
delivered when troops in reserve fire from high ground, over the heads 
of their comrades, at the opposing force. 

Hand Weapons, — This is a class of firearms to which the term hand- 
weapon has been given because they are carried by the soldier and 
fired from the hand or shoulder. This class includes the military rifle, 
the carbine, revolver and pistol. 

The Military Rifle. — This weapon is now carried by all soldiers 
of the line except field artillery, viz.: cavalry, infantry, the marines 
and sailors. It represents the perfected weapon which has been 
evolved in the process of gun-making from the hand-cannon to the 
magazine breech-loading rifle. In order to properly appreciate the 
significance of the military rifle, the following summary of the dif- 
ferent stages in the development of firearms will be of assistance 

Hand Cannon. — These guns originated in the East, from which they 

were introduced into Europe in 1446. They were the first portable 

firearms of which we have any record. The hand-cannon was a small 

cannon carried by two men and was fired from a rest on the ground 

.and later from two-forked sticks. 

Hand Gun. — The hand gun followed the hand-cannon; the barrel 
was longer and was made of brass fixed in a wooden stock, and like its 
predecessor, was fired by a lighted match applied by the hand to a 
touch hole at the rear end of the barrel. The projectiles were made of 



4 GUNSHOT WOUNDS 

stone, iron, or lead, and the recoil was received by a breast plate in- 
stead of the shoulder. 

Match Lock. — The hand gun was followed by the match lock, 
which was provided with a swinging cock holding a burning taper. 
The latter was gradually approached to the powder in the firing-pan 
around the touch hole, by pressing a trigger, underneath, with the 
finger. These weapons were used in war for nearly two hundred years, 
when guns with more complicated devices were adopted. 

Wheel Lock. — This is a gun invented in Germany about 1515. 
The powder in the pan was ignited by sparks, which emitted from 
sulphurous pyrites resting against a rapidly revolving wheel set in motion 
by pressing the trigger. 

The Snap Haunce Gun. — This gun followed the wheel lock. It 
derives its name from a pecking hen. In this the wheel was replaced 
by a cock which struck a steel-faced cover over the pan. It employed 
pyrites to produce the spark and it preceded the use of the more 
effective flint lock. The operation of firing with all the preceding 
weapons was slow, about one shot per minute. The bullets were round, 
weighing 10 to the pound. 

The Flint Lock. — This mechanism employed a flint fixed in the 
hammer which on striking the steel-faced cover of the pan caused 
sparks to ignite the powder overlying the vent or touchhole. It was 
first used by the French and English in about 1642 and descended 
to us from these nations during the earlier settlement of our country. 
It continued in use for nearly two hundred years, when it was replaced 
by the percussion cap gun. It is the gun with which we fought our 
first three wars. At the beginning of the last century, the size of its 
balls was reduced from 10 to 14 1/2 to the pound, the charge of powder 
was 6 drams, and the bore of the gun was .753 inch diameter. 

Percussion Cap Gun.- — The percussion musket has a hollow pin 
screwed into the vent which insures direct communication with the 
powder charge. A copper cap charged with fulminate powder is 
placed over the pin which on being struck by the hammer detonates 
and in turn ignites the explosive in the chamber of the gun. It was 
first used in the English Army in 1839 (though invented in 1807) and 
in our army in 1842. 

The smoothbore percussion musket used in the armies at this time 
had calibers ranging from .63 to .75. It fired a bullet made of soft 
lead weighing from 315 to 400 grains and the charge of black powder 
was from 75 to 130 grains. The projectiles were round with initial 
velocities ranging from 540 to 950 feet per second and the effective 
range rarely exceeded 350 yards. 



FIREARMS 



The imperfect fit of the ball in smoothbore barrels permitted the 
escape of so much of the powder gases at the time of discharge of 
these guns, with consequent loss of velocity and energy, that the gun 
makers next turned their attention to the correction of this defect, and 
in so doing they evolved the hand rifle, which has since become so valu- 
able to the soldier and sportsman. 

The Military Rifle. — The earlier patterns of rifled arms still em- 
ployed round balls in barrels with straight grooves. The balls were a 
trifle larger than the bore of the gun, and they were forced down to the 
charge by the use of a ramrod. Later the bullets were elongated to 
allow more of the surface of the missile to come in contact with the 
barrel. The fit of the ball was so tight that it was necessary to employ a 
hammer in addition to the ramrod, and hammers for the purpose 
were added to the equipment. This secured a better fit between the 
ball and barrel, which in turn added to the energy and extended the 
range of the ball by retaining it longer in the barrel while the explosive 
was generating gases in greater volume and consequently adding greater 
pressure. The elongated bullets fired from the first rifles were apt 
to tumble or lose their balance, and this was overcome in a measure 
by giving the straight grooves in the barrel a slight twist or spiral 
turn at the rate of one complete turn in 78 inches. This added sta- 
bility to the bullet, keeping its point forward in flight for a greater time, 
and it also added to the range, energy and accuracy of fire. This 
principle in ballistics and the improvement of explosives have added 
greatly to the effectiveness of projectiles. 

To overcome the extreme difficulty and the loss of time in loading 
with the ramrod and hammer, in 1841 Delvigne, a French army officer, 
conceived the idea of making a hollow in the base of the bullet next to 
the explosive, so that the force of the gases might press the soft lead into 
the metal grooves in the barrel. This prevented the escape of gas and 
added to the value of the rifle. Later, in 1847, Captain Minie sug- 
gested placing an iron disc in the cup at the base of the bullet. The 
pressure of the gases forced the iron disc forward, thereby securing more 
expansion of the lead. This added greatly to the effectiveness of 
weapons, and although Captain Minie' s improvement related only to 
the projectile, the rifles of that day generally went by the name of 
Minie rifles. The iron device in the bullet, which was later changed 
to a boxwood plug, was employed in the Enfield rifle of the English 
and by other armies, whatever might be the name of their weapons. 

The following were the principal features of the Minie rifle corre- 
sponding with the earlier makes of our Springfield rifle: 



GUNSHOT WOUNDS 

MINIE RIFLE, 1851 to 1866 

Weight with bayonet 10 lb. 8 3/4 oz. 

Diameter of bore 702 inch. 

Number of grooves 4 

Twist 1 turn in 78 inches. 

Diameter of bullet 690 inch. 

Weight of bullet 680 grains. 

Charge of powder 150 grains. 

Sight for 100 to 1000 yards. 

In 1855 we made still further reductions in the muzzle-loading 
Springfield rifle, as follows: 

Caliber 58 inch. 

Weight of bullet 500 grains. 

Charge of powder 60 grains. 

The twist was shortened to one turn in 36 inches, and this was the gun 
used by our army until 1866. 

Breechloaders. — The desire of tacticians to increase the rapidity 
of fire on the line, led to the adoption of breech-loading weapons. 
Although breechloaders were known since the reign of Henry VIII, 
they never came into practical use until the Germans used the device 
under the name of the Needle Gun in the Austro-Prussian War of 1866. 
At this time we converted the Springfield rifle of our army to a breech- 
loader by adding a breech lock which was made to work on a hinge 
forward, and we reduced the caliber to .50. The device was simple; 
slight pressure of the thumb of the right hand opened the chamber for 
the reception of the metallic cartridge which had then come into use. 
Our troops were equipped with this gun till 1873, at which time a new 
model was introduced. The caliber was reduced to .45, the twist was 
shortened to 1 turn in 22 inches to give the elongated bullet more 
stability, the powder charge was retained at 70 grains, and the weight 
of the bullet was reduced to 405 grains. These improvements in- 
creased the velocity to 1315 f.s. with a point blank range of 350 yards 
and a maximum effective range of 2000 yards. We now had a weapon 
which inexpert hands could be fired as of ten as twenty shots per minute. 
This was one of the most effective guns of its time. It compared with 
the German Mauser, the Lee-Speed of the English, the Lebel of the 
French, and the Spencer, Sharp and Maynard of the sporting world. 
The ingenuity of man had thus caused rapid strides in gunmaking 
in one generation, but those who marveled at these marked changes 
were scarcely prepared for the wonderful improvements that were soon 
to follow. 

Magazine Breechloaders with Reduced Caliber. — The rapid means 



FIREARMS 7 

of locomotion in modern times have made it possible to concentrate 
large bodies of troops at weak points, and to ward off attacks by means 
of inferior numbers, so that tacticians sought greater rapidity of fire. 
This led to the introduction of the magazine rifle, a weapon which 
carries five or more cartridges in a magazine that may be placed 
(a) in a tube under the barrel, (b) in a tube in the stock, (c) detachable 
or fixed under the receiver, or (d) to one side of the receiver. Guns 
with fixed magazines under the receivers are preferable. Such maga- 
zines give the piece better balance and have been adopted by nearly all 
the great military nations. Our first magazine rifle of reduced caliber 
was adopted in 1892 under the name of the Krag-Jorgensen rifle, named 
for its inventors, two Norwegians. This weapon differed from its prede- 
cessor, the Springfield breech-loading rifle, in caliber, and the adoption 
of the magazine which is placed below and to the right of the receiver. 
Its principal features were as follows : 

Magazine fixed, right side yes. 

Clip 5 cartridges. 

Cut-off yes. 

Safety lock yes. 

Weight without bayonet 9.19 lbs. 

Length of barrel 30 inches. 

Caliber, inches — mm 30-7 . 62 

Number of grooves 4 

Depth of grooves 004 

Length of twist, turn 1 in 10 inches. 

Direction of twist to right. 

Weight of cartridge 435-442 grains. 

Bullet, material of envelope cupro-nickel steel. 

Bullet, material of core lead and tin. 

Bullet, length of 1 .26 inches. 

Bullet, diameter 308 inch. 

Bullet, weight of 220 grains. 

Weight of charge 35-42 grains. 

Propellent smokeless, nitrocellulose. 

Initial velocity 2000 feet per second. 

Velocity of rotation of bullet, muzzle 2400 turns per second. 

Muzzle energy in foot-pounds 1954. 

The other features of the gun are described by Major George D. 
Deshon, 1 M. C, U. S. A., as follows: 

"The magazine is below and to the right of the receiver. Access 

to it is gained by a gate, hinged below, which opens parallel to the bore. 

The cartridges are dropped sideways into the receiver through the 

open gate, either singly or in any number up to five at one time, which 

1 Association Military Surg. Journal, Vol. Ill, 1893. 



8 GUNSHOT WOUNDS 

is the capacity of the receiver. Closing the gate presses a spring 
on the cartridges, forcing them successively around under the re- 
ceiver and finally into it from the left side. A cartridge having 
thus been placed in the receiver, the bolt handle is pushed forward 
and then downward and to the right, the bolt pushing the cartridge 
forward into the chamber, and a lug on the forward end of the bolt 
engaging in a recess in the bottom of the receiver firmly locks the 
bolt and sustains it under the shock of discharge brought about 
by pressure on the trigger. To open the receiver the bolt handle is 
turned upward and to the left and then pulled directly to the rear. 
The first part of the movement retracts the firing-pin and unlocks the 
bolt. A hook on the front end of the extractor, which lies along the 
bolt, next catches the flange of the empty shell and draws it back until 
it meets a lever in the floor of the receiver by which it is thrown out to 
the ground. A cut-off is provided on the left of the receiver whereby 
the cartridges in the magazine may be at any time shut off and held in 
reserve at the will of the soldier. The special advantages of this gun 
are the ease and simplicity of its bolt action and the facility with which 
it can be at any time loaded, either singly or as a repeater. It makes 
no difference whether the magazine is empty or partly full, whether the 
bolt is forward or back, whether the cut-off is open or closed, the gun 
can still be loaded with ease and always in the same manner, thus 
fulfilling every need of the hardened veteran or the impressionable 
recruit." 

This gun corresponds in effectiveness for war to the guns of other 
nations that were adopted at about this time. In 1903 a new arm was 
perfected, somewhat similar in its magazine and bolt to the German 
Mauser Rifle. This is known as the United States Rifle, cal. .30, 
model of 1903. The weight of this, the present service rifle, is about 

9 1/2 pounds; length of barrel, 24.006 inches. In 1906 radical 
changes were made in the ammunition, as follows: The weight of 
the bullet was reduced from 220 to 150 grains. Instead of an 
ogival head the present bullet is pointed, offering less resistance to 
the air. Its length has been reduced from 1.26 inches to 1.08 inches. 
The powder charge has been increased from about 38 grains to about 
48 grains. The muzzle velocity of the new bullet has been increased 
from 2000 f.s. to 2700 f.s., and the velocity of rotation at the 
muzzle from 2400 turns to 3240 turns per second. The striking 
energy has been increased from 1954 to 2400 foot-pounds. The 
extreme range has been increased from 4066 to 4891 yards. Twenty- 
three aimed shots have been fired in one minute with this rifle used 



FIREARMS 



9 



as a single loader and forty shots in the same time from the hip with- 
out aim using magazine fire. The ball penetrates 28.25 inches of 
thoroughly seasoned oak across the grain at 50 feet, Fig. 1. In the 
modern rifle 1 the ratio of weight of bullet to weight of gun is much 
less. Though the velocity of the bullet has increased very much, the 
velocity of recoil is less, and the soldier is able to withstand much 
longer the shock of recoil on the shoulder with less fatigue. Increased 
muzzle velocity has added to the range and accuracy of fire. The tra- 
jectory is flatter and the danger space has been increased for all ranges. 
These advantages have been attained with a shorter barrel, which 
diminishes the weight of the gun and facilitates handling by the soldier. 
Using the battle sight, the point blank danger space is as follows: 

Firing standing 203 yards. 

Firing kneeling 636. 6 yards. 

Firing lying down 587 . 2 yards. 




Fig. 1. — The relative penetration of U. S. Army rifle bullets in well-seasoned oak across the 
graiD at 50 feet. 1, Penetration of .45 cal. Springfield rifle bullet, weight 500 grains, 3.2 inches; 
2, penetration of .30 cal. Krag-Jorgensen rifle bullet, weight 220 grains, 19.5 inches; 3, penetration 
of .30 cal. new Spiingfield rifle bullet, weight 150 grains, 28.25 inches. 

The gun is sighted for 2850 yards. In many respects this is one of the 
most effective guns now used by any army. The center of gravity of 
the bullet is placed well back, giving it but little stability on striking 
structures offering the slightest kind of resistance — a question which 
will be discussed in a later chapter. 
1 Ordnance and Gunnery, Lissak. 



10 GUNSHOT WOUNDS 

Carbine. — This is a firearm carried by cavalry. It is very much like 
the military rifle, using the same or lighter ammunition, but with shorter 
barrel. In the evolution of the military rifle nearly all mounted troops 
have hitherto been provided with a carbine, since it is more easily carried 
on horseback. In the recent change in our service to the U. S. magazine 
rifle, we have so shortened the barrel of the latter that it is easily carried 
by mounted troopers and the present weapon answers the purpose of 
both branches of the service — cavalry and infantry. 

Shotgun. — This gun is so familiar to everyone that it requires no 
particular description. The more important subject of missiles and 
powder charge will be described later. 

Revolvers and Pistols. — The familiar examples of revolvers in this 
country are the Smith and Wesson and the Colt new service double- 
action revolver. The United States Army was formerly provided with a 
.45 caliber Colt revolver, and later the caliber was reduced to .38 
inch. The latter is a double-action weapon, 1 that is, it can be fired in 
either of two ways, by separately cocking the hammer and pulling the 
trigger or by accomplishing both operations with a steady pull on the 
trigger. When rapidity of action is required, the double-action mechan- 
ism is employed, but the fire is not so accurate. After using this 
weapon a number of years its stopping power was not considered 
sufficient. The United States Government, after many trials of the 
various automatic pistols, viz., the Savage, Luger, and Colt, of calibers 
varying between .32 and .45, recently adopted the .45 caliber Colt 
automatic pistol. 

The Colt Automatic Pistol. — In this weapon there is a movable 
barrel and slide, the recoil of which ejects the empty shell, cocks the 
firing mechanism, and loads a new cartridge into the barrel. After 
the first shot is fired it is only necessary to pull the trigger for each 
succeeding shot as long as a cartridge remains in the magazine. The 
magazine of the . 45 caliber pistol holds seven cartridges, while that of 
the . 32 and . 38 calibers holds eight cartridges. The magazine is 
enclosed in the hollow handle, is inserted from below, and is held in 
place by a spring and catch. 1 The bullet, composed of a lead core 
encased in a jacket of cupro-nickel, weighs 230 grains. The charge 
is about 5 grains smokeless powder, and the initial velocity about 900 f .s. 
The automatic pistol is superior to the revolver as a service arm for 
the following reasons : 

1. Great accuracy. 2. Less recoil. 3. Rapidity of fire. 

4. Greater number of shots. 5. Rapidity of loading. 

1 Ordnance and Gunnery, by Lissak, op cit. 



EXPLOSIVES 11 

Reloading is done in an instant by inserting an extra magazine. 
The moral effect of having this reserve ammunition under complete 
control will be of great value. 

Toy Pistol. — This is really a revolver of about . 22 calibers, employing 
generally a blank cartridge composed of a brass shell and a charge of 
about 6 grains of black powder, held in place by a cardboard wad. It 
is used in this country by boys generally to celebrate the anniversary 
of our National Independence. Accidents from this weapon have 
figured extensively in medical literature under the head of toy pistol 
tetanus or 4th of July tetanus, to which we will refer later. 

The Flobert and other target rifles, used in shooting galleries, are 
generally .22 to . 38 calibers in diameter. They shoot round or 
elongated bullets with velocity and energy sufficient to penetrate any 
part of the body, including the skull and brain. 

3. EXPLOSIVES 

The marked advances in the effectiveness of present-day firearms 
are largely due to the use of modern explosives, which have almost 
entirely superseded the use of black gunpowder as a propellent. The 
latter still has some valuable uses, and among explosives it is generally 
the first to be described. 

Gunpowder is an explosive substance formed by a mechanical 
mixture of 

Saltpeter 75 per cent. 

Charcoal 15 per cent. 

Sulphur 10 per cent. 

100 per cent. 

Gunpowder explodes when heated to 572° F. In guns it is exploded 
by striking the primer in the base of the cartridge which is charged 
with fulminate powder. Its value as a propellent is due to the large 
amount of gas which it liberates on exploding. The chemical results 
of this explosion are: 43 per cent, of gaseous products composed of 
carbonic acid, and nitrogen with some carbonic oxide and aqueous 
vapor. The remainder of the charge is associated with the gases in 
the form of finely-divided solid substances. The volume of the gases 
at zero centigrade and under atmospheric pressure, liberated by the 
explosion, occupies 280 times the bulk of the charge. The pressure 
exerted in a closed vessel is said to be as much as 5850 atmospheres 



12 GUNSHOT WOUNDS 

when the charge is exploded in a space completely filled by it (Noble & 
Abel). The temperature of the products of explosion reaches from 
2000° to 4000° C. In the explosion which takes place, charcoal fur- 
nishes the carbon and niter furnishes the oxygen to burn the charcoal 
and sulphur. In addition, the latter adds to the rapidity of the 
explosion. 

Modern Explosives. — These have many uses, but to the surgeon 
they are of special interest when employed in war and by evil doers 
in attempts to destroy human life. The following are the ones more 
often resorted to for the purposes mentioned. 

Fulminate Powder. — Although there are other fulminate powders, 
the fulminate of mercury is the only one used for military purposes. 
It is used as a detonator in exploding guncotton and other explosives, 
and also in charging percussion caps. It explodes instantaneously and 
with great force by friction and by percussion. When wet it may be 
handled with impunity, and when dry it burns quietly when kindled 
in the open air. It explodes when heated to a temperature of 360° F. 
The gases of the explosion are C0 2 , N and vapor of mercury. Its 
distinguishing characters are the large volume of gas generated for 
the bulk of the substance used, and the rapidity and violence of the 
explosion. The theoretical pressure developed by the explosion of this 
body is 28,000 atmospheres. The explosive characteristics of the sub- 
stance were displayed in the Orsini attempt to assassinate the French 
Emperor in 1858, when three bombs were exploded, each containing 4 
ounces of mercuric fulminate: 511 wounds were inflicted on 156 persons. 

Smokeless Powders. — The name of these explosives comes from 
the fact that they emit "very little smoke on exploding as compared 
to black gunpowder. Two classes of smokeless powders are now or 
have been recently in use in our service : Nitroglycerin powder, used 
for the hand weapons, and nitrocellulose powder, now used for both 
small arms and cannon. They are both made from guncotton, but 
the nitroglycerin powder has from 10 per cent to 30 per cent of 
nitroglycerin. The temperature of the explosion of the latter material 
is higher, and as the erosion of the metal of the bore increases with the 
temperature, the life of the large costly guns is very much shortened 
by the use of the nitroglycerin powder. For this reason nitrocellulose 
powder is generally preferred for use in cannon. Another objection to 
the use of nitroglycerin powder for large guns, was its greater liability 
of spontaneous ignition when deteriorating in unfavorable storage 
conditions. In the hand weapons, the nitroglycerin powder is 



EXPLOSIVES 13 

hermetically sealed in the cartridge, and its keeping qualities and 
stability are preserved, and for these reasons it can be used with safety 
in small arms. 

One of the typical nitroglycerin powders used abroad is composed 
of— 

Insoluble nitrocellulose 67. 25 per cent. 

Nitroglycerin 30 . 00 per cent. 

Metallic salts 2 . 75 per cent. 

100.00 per cent. 

Forty pounds of acetone is the solvent for a hundred pounds of this 
mixture. The jelly-like paste, after various treatments in shaping and 
drying, is cut into bead-like grains, perforated and graphited. 

Cordite. — This is an English nitroglycerin powder, composed as 
follows : 

Nitroglycerin 30 per cent. 

Guncotton 65 per cent. 

Vaseline 5 per cent. 

100 per cent. 

The vaseline is added to render the powder waterproof and to improve 
its keeping qualities. 

Nitrocellulose Powder. — This is the powder used in cannon. It 
is»composed of guncotton containing 12.65 per cent nitrogen dissolved 
in two parts of ether to one of alcohol. The powder issues from the 
press as a colloid, and it is cut into grains of suitable size and prepared 
as stated under nitroglycerin powder, except that cannon powder is 
not graphited as a rule. In our service the powder is formed into 
cylindrical grains with seven longitudinal perforations giving a uniform 
thickness of web. The powder is brown in appearance and the grain 
differs in size with the caliber of the gun. 

In other services cannon powders are made into grains of various 
shapes, such as cubes, solid and tubular rods, circular cross-section, 
flat strips, and rolled sheets. 

The advantages of smokeless powder lie in the fact that, unlike 
black powder, the smokeless powder is almost entirely converted into 
gas; and with smaller charges it is possible to give equal or higher 
velocity to the projectile; it leaves no residue in the bore. The theo- 
retical pressures when exploded in its own volume, exerted by guncot- 
ton, is 24,000, and as much as 25,000 atmospheres by nitroglycerin — 



14 GUNSHOT WOUNDS 

more than four times greater than that developed by the explosion of 
gunpowder. 

There are other explosives of interest to the surgeon. They are 
the so-called picric acid compounds, known under the familiar names 
of melenite, emmensite, liddite, etc. They emit fumes on exploding 
which irritate the conjunctiva and air passages. 

The Sprengel explosives, known under the names of bellite, hellofite, 
and roburite, are high explosives which are harmless when the compo- 
nent parts are kept separated; when mixed they detonate with great 
violence. 

Compressed Atmospheric Air. — Compressed air is used as a pro- 
pellent in air guns in shooting galleries principally. Compressed air 
has no application as an explosive in military practice because of the 
limited range which it confers on the projectile. 

4. PROJECTILES 

The term projectile is applied to missiles from firearms in general. 
The term as used in these pages is synonymous with the term bullet 
when it refers to projectiles from hand weapons. Missiles propelled 
by the bursting charge of grenades, bombs, and mines are also referred 
to as projectiles. 

Projectiles may be divided into three classes: 

1. Projectiles from hand weapons. 

2. Projectiles from artillery. 

3. Projectiles from grenades, bombs, and mines. 
Projectiles from Hand Weapons. — The hand weapons include 

rifles, pistols, and revolvers, shotguns, and air guns. The present- 
day projectiles from hand weapons, pistols, and revolvers are con- 
veniently classed as follows: (a) penetrating bullets, (b) setting-up 
bullets, (c) disintegrating bullets, (d) explosive bullets. 

(a) Penetrating Bullet. — This is a bullet made up of a core of hard 
lead enclosed in a mantle of cupro-nickel steel. It is the bullet of the 
reduced caliber military rifle the world over, and it is also employed in 
the automatic pistols that are now coming into such favor. This 
bullet rarely disintegrates in the human body, and it seldom deforms. 
When making a regular impact it generally penetrates point on. 

(b) Setting-up Bullet. — This bullet is made of soft lead in order to 
promote deformation on impact against bony structures. This was 
the bullet of olden times before the days of rifle weapons and until 
the lead was hardened with antimony. 



PROJECTILES 



15 



(c) Disintegrating or Dum-dum Bullets. — These bullets are also ^y 
called metal patch bullets in the trade. They are mantled projectiles 
except at the tip end, where the lead core is fully exposed. Such a 
bullet readily disintegrates on impact against resistant structures like 
bone. The core and the steel case break up into many fragments, each 
acting as a projectile. 

(d) Explosive Bullets. — These projectiles are hollow lead bullets in 
which an explosive is placed. A cap is fixed in the nose of the bullet ^/ 
to promote explosion on impact. The effects of such a bullet do not 
differ from those of a dum-dum projectile. Their use is proscribed by 

the comity of nations. 

In addition to the foregoing projectiles, armies generally have blank 
ammunition in which the bullet is replaced by a wad of cardboard, 
or paper. This blank ammunition is used for ceremonies and drills. 



CAL. .45 

SPRINGFIELD RIFLE 

BULLET 



CAL. .30 

MODEL OF 1903, 

BULLET 




CAL. .30 

MODEL OF 1906, 

BULLET 




CAL. .38 

REVOLVER 

BULLET 



CAL. .45 

AUT. PISTOL 

BULLET 





LENGTH-INCH 


1.31 


1.26 


1.08 


.67 


.66 


DIAMETER-INCH 


,456 


.308 


.308 


i33 


.4-5 


WEIGHT-GRAINS 


500 


220 


150 


148 


23.0 



Fig. 2. — 3 and 5 represent the shape and size of the rifle and pistol bullets in present use by the 
United States Army. 1, 2 and 4 represent the rifle and revolver bullets recently discarded. 



Projectiles from Pistols and Revolvers. — These correspond very 
nearly in caliber and composition to the projectiles of the military 
rifle. They usually weigh less and they are shorter. For special 
reference to their shape and composition see Fig. 2, also table No. 3, 
pages 72 and 73. 

Shotgun projectiles vary from fine lead pellets, 2020 to the troy 
ounce, to buckshot, which are .31 inch in diameter. The smallest 
pellets weigh a fraction of a grain and the buckshot weigh 38 grains. 
Shotgun projectiles are all-round, and they are composed of hard lead. 
The number of missiles to each cartridge depends on the bore of the 
gun and the size of the pellets. 



16 



GUNSHOT WOUNDS 



The projectile from the toy pistol is the entire charge, which 
is made up of the cardboard wad and about 6 grains of black 
powder. 

The projectile from the air gun and Flobert rifle is an elongated or 
a .22 BB round shot made of lead hardened with antimony. 

Projectiles from Artillery. — These are classed as shot, shell, and 
case shot. 

Solid shot is no longer used in modern cannons. The projectile 
called a shot is now hollow with thick walls. It is principally used to 
perforate armor and carries a small bursting charge. 

Shell. — The shell is a hollow projectile with thinner 
walls than the preceding. It is also provided with a 
large bursting charge. It is used to destroy persons 
or material (Figs. 3 and 4). 

High-explosive Shell. — This projectile has come into 
high favor in the present European War. Although 
used primarily for stationary and large siege guns, it 
is now used with good effect on the field in the "77" 
and "75" guns of the mobile artillery of the Germans 
and French in battering down barbed wire entangle- 
ments and other obstructions used against the ad- 
vancement of troops. The shell is made to explode 
on impact only. (Plate A, Fig. 1.) It bursts into 
many irregular fragments of varying sizes. The larger 
fragments cause lacerated wounds which contain much 
devitalized tissue and which are difficult to treat. 

Pom-pom shell is another kind of shell. It derives 
its name from the report of its discharge. ■ It is fired 
from the one-pounder Vickers-Maxim automatic 
gun. It is 1.457 inches in diameter, 3 3/4 inches in 
length, and weighs 16 ounces. It explodes by per- 
cussion. This shell is used to kill and wound the 
enemy, hence like the cannon shell it breaks into many fragments. 

Case Shot. — This consists of a number of shot held together in a 
metal case, which may be ruptured by the shock of discharge, or by a 
bursting charge. The term canister or grape shot is applied to the 
former and the term shrapnel is applied to the latter. The modern 
projectiles of the artillery arm are all cylindrical with an ogival head, 
except the canister, which has a flat head. 

Canister. — In this projectile the metallic envelope is filled with 




Fig. 3.— The 3- 
inch common steel 
shell used in U. S. 
Army. 



GUNSHOT WOUNDS 



Plate A 




Fig. 1. — A high-explosive shell in cross section. 




Fig. 2. — A type of high-explosive shrapnel. 
From Report of the Medico-Military Aspects of the European War. By Surgeon A. M. Faunt- 
leroy, U. S. N. Washington, Government Printing Office, 1915. 



Facing page 16. 



PEOJECTILES 



17 




+3 

T3 



a 

3 



P=H 



a 

M 



18 



GUNSHOT WOUNDS 



small balls which are liberated by the sl\ock of discharge. Canisters 
are used at short range when the guns of a battery are in danger of 
capture. Each 3-inch canister contains 244 iron balls, 5/8 of an inch 
in diameter, weighing 30 to the pound, placed in a receptacle the shape 
of an elongated can. The canister has been entirely superseded by the 
modern shrapnel. 

The Shrapnel. — The shrapnel is of special interest to surgeons 
because of its increasing importance in augmenting the casualty list 
of battles in modern wars. The shrapnel is a projec- 
tile which carries a number of bullets at a distance 
from the gun where they are discharged with added 
energy over a wide area from the point of bursting. 
It has become the principal projectile of all modern 
field artillery. It forms 80 per cent of the ammuni- 
tion supply of the field guns. 1 It is used against 
troops in masses and material as well. It is used, 
also, in mountain and siege artillery, and in the 
smaller guns of sea coast fortifications to repel land 
attacks. (See Fig. 5.) In this shrapnel the case is 
a steel tube with a solid base. The weight of the 
3-inch field-gun shrapnel complete is 15 pounds, 
length 10 inches, muzzle velocity 1700 f.s. The burst- 
ing charge is composed of 2 3/4 ounces black powder 
pJaced in the chamber at the base. There is a stop- 
per of guncotton in the central tube to hold the 
powder in place and to assist in the explosion. There 
^ . „ are 252 round balls, flattened on six faces, of .50 inch 

Fig. o. — C o m- ' ' 

mon shrapnel used caliber, composed of lead hardened with antimony, 
m u. s. Army. rj-^ ^gjjg are surrounded by a smoke-producing matrix, 

which is used to locate the point of bursting. This 
shrapnel is said to be a man-killer at 6500 yards. At the latter dis- 
tance the shrapnel has a remaining velocity of 565 f.s. On bursting, 
an additional velocity of 300 f.s. is conferred on the lead bullets, 
making altogether a remaining velocity of 865 f.s. at 6500 yards. 
The fuse can be set to cause the projectile to explode at any one-fifth 
of a second in its flight. 

The older shrapnels were made up of a cast-iron case and dia- 
phragm that separated the balls. The case was constructed to invite 
rupture into a number of fragments. The bursting charge was placed 
1 Ordnance and Gunnery, by Lissak, op. cit. 




FIREARMS 19 

generally in the head of the projectile. This old-time shrapnel broke 
into a greater number of fragments, but they were not always 
•possessed with sufficient energy to inflict severe injury. The present 
shrapnel has the bursting charge located in its base. It is made of 
a stout case, which remains intact at the time of bursting, except 
for the blowing out of the head. 

High -explosive Shrapnel. — This is a combination high-explosive 
shell and shrapnel. It is used against personnel and materiel, and it 
answers well the objects of both projectiles. When it is desired to 
use the projectile as a shrapnel it is made to explode by a time fuse 
in the air in front of the enemy. When used as a high-explosive shell, 
the time fuse is not set, and it is allowed to explode on impact. The 
shell is one of the inventions of the present war. Its degree of useful- 
ness has not been entirely established. (Plate A, Fig. 2.) 

Fauntleroy 1 states, that at the beginning of the war, ammuni- 
tion was issued to the "75" French gun in the proportion of one-half 
shrapnel and one-half high-explosive shell. On account of the superior 
efficiency of the latter, the manufacture of shrapnel has been discon- 
tinued. The high-explosive shell not only kills by the direct effects 
of the fragments liberated at the time of bursting, but there is evidence 
that death may be the result of the shock of impact from the sudden 
displacement of air. It is common to find men dead in the vicinity 
of an explosion without any evidence of external injury. The ex- 
plosion is so violent that soldiers have been hurled 10 feet into the air 
by the bursting of the high-explosive shell. 

The following table gives the area of dispersion and other important 
data on shell and shrapnel used in guns of different calibers. 

Grenades, Bombs, Mines, and Torpedoes. — Hand and rifle grenades 
have recently come into prominence as projectiles. Hand grenades 
were among the earliest forms of explosive projectiles used in war. 
Trained soldiers, called grenadiers, threw grenades by hand in repell- 
ing attacks, etc. The earlier grenades were composed of a hollow 
ball or cylinder of metal, glass or paper, 2 or 3 inches in diameter, 
filled with an explosive which was exploded by a fuse upon 
falling among the enemy. Their employment was abandoned 
in the latter part of the seventeenth century. Dynamite 
grenades were first used at the siege of Mafeking by the besieged. 
The modern grenade came into special prominence in the Russo- 

1 Surgeon A. M. Fauntleroy, U. S. Navy, Report on the Medico-Military Aspects 
of the European War. Government Printing Office, 1915. 



20 



GUNSHOT WOUNDS 



Japanese war as a result, no doubt, of the great advances in the 
application of high explosives. The hand grenade of the Japanese 
is suspended from the cartridge belt, Fig. 6. It consists of two 
parts, the body and the handle. The body is a tin cylinder, 4 1/2 



AREA OF DISPERSION 







Shrapnel 


Shell 




• 


Length, 
yards 


Width, 
yards 


Length, 
yards 


Width, 
yards 


- Area of dispersion about 
100 yards wide and 150 
yards long, very effect- 
ive within a central 
zone of about 30 yards 


At a range less than 
3000 yards. 


Field gun 
Mountain 
howitzer 


400 
300 


150 
100 


300 

250 


100 
75 


At a range over 3000 
yards. 


Field gun 
Mountain 
howitzer 


300 
200 


125 

75 


250 
150 


75 

75 


wide and 20 yr,rds long. 



FIELD ARTILLERY 









Shrapnel 




Shell 




Extreme 
range, 
yards 












Gun 




No. of 
bullets 


Size and 




Approximate No. 




Weight 


weight of 
bullets 


Weight 


of effective frag- 
ments 


3-inch field gun and 


Gun 












mountain howitzer. 


6500 

Howitzer 

5600 


15 lb. 


252 


.5 in. 
167 grains 


15 lb. 


600 


3 . 8-inch gun and 


Gun 












howitzer. 


7300 

Howitzer 

6200 


30 lb. 


340 


. 54 in. 
230 grains 


30 lb. 


800 


4 . 7-inch gun and 


Gun 












howitzer 


8000 

Howitzer 

6640 


60 lb. 


711 


. 54 in. 
230 grains 


60 lb. 


1000 


6-inch howitzer 


6704 


120 lb. 


1074 


. 6 in. 
306.4 grains 


120 lb. 


1500 



FIREARMS 



21 




Fig. 6. — Dummy of a Japanese hand grenade. 



Fig. 7. 



22 



GUNSHOT WOUNDS 



cm. in diameter by 6 cm. in length, filled with shimose powder and 
provided with a time fuse. The cylinder is also provided with a per- 
cussion cap at the far end. To ensure the grenade falling cap-end 




Fig. 8. 



first, it is piloted by a kite-tail arrangement placed at the rear end of 
the handle, and a weighted lead ring is fixed on the base at the opposite 
end of the grenade, which is provided with the cap. The grenade 




ft %• * -*■> * *| ^ & m' 






Fig. 9. 



breaks into many fragments, and in addition it emits a gas which 
causes painful irritation to the conjunctiva and air passages. 

" In the latter part of the war at Port Arthur the Japanese abandoned 
the hand grenade for a can filled with a high explosive which was placed 



PROJECTILES 23 

in a small mortar. Some of the latter were made of wood, in which a 
small charge of powder gently lifted the can, which was usually filled 
with shimose, from 200 to 400 yards, where a frightful explosion would 
occur" (Lynch). 

In our service we employ a grenade (Fig. 7) which corresponds very 
nearly to the Japanese hand grenade, except that the body is made 
of steel instead of tin. There is also a grenade fired from the rifle, as 
shown in Fig. 8. This is a great advantage, as the body of the soldier 
need not be exposed in propelling the grenade, as in the case of the hand 
grenade of the Japanese army. Fig. 9 shows the fragmentation of the 
U. S. grenade. 

Hand Bombs. — These projectiles were extensively used by both 
combatants in the Russo-Japanese war at Port Arthur. The bomb 
of the Japanese weighed about 14 pounds. It was composed of pyrox- 
ylin and melenite placed in linen bags provided with a fuse of fulminate 
of mercury. The bags were suspended from the soldier's neck, and 
they were thrown among the enemy at opportune moments. The 
Russians employed a hand bomb, composed of 600 to 1400 grams of 
different kinds of explosives loaded into the copper case of their empty 
3-inch shells, provided with a fuse. The destructive effects of such pro- 
jectiles are similar to those of guncotton, viz., the violent displacement 
of air as detonation takes place. 

Mines and Torpedoes. — Mines and torpedoes figure extensively in 
naval combat and in harbor defenses. The land forces are specially 
interested in terrestrial mines which, like submarine mines, torpedoes, 
etc., are made by confining a charge of explosive in a case which is 
exploded by clock-work, by contact, or by an electric spark under the 
control of an individual at a central point. The terrestrial mines of 
the combatants in the Russo-Japanese War were composed of wooden or 
metallic cases holding about 12 pounds of pyroxylin. The cases were 
buried 3 feet underground about 200 yards from the line of defense, 
disposed in two rows 40 to 50 yards apart, the mines in each row being 
disposed at intervals of 10 to 12 yards. The projectiles set in motion 
with each explosion were made up of dirt, gravel, pieces of the 
casing, and the rapidly displaced air at or near the locality of the 
explosion. 

Projectiles from Gatling and automatic machine guns are the same 
as used in the hand rifle of foot troops described under the term 
penetrating bullets in the beginning of this chapter, and which will be 
referred to extensively in succeeding chapters. 



24 GUNSHOT WOUNDS 

5. BALLISTICS 

I. Motions of Projectiles. 

(A) The motion of translation. 

1. The force of explosion. 

2. Air resistance. 

3. The force of gravity. 

4. Combined effect of forces. 

(B) The motion of rotation. 

II. The Trajectory. 

(a) The danger space. 

(b) Factors that affect the trajectory. 

(c) Sectional density and form. 

1. THE MOTIONS OF PROJECTILES 

Projectiles of early form fired from smoothbore guns, being spher- 
ical, had but one motion imparted to them, that of translation. To 
oblong projectiles, in addition to the motion of translation, is given a 
motion of rotation to steady them in their flight. Attention will be 
given first only to the motion of translation. 

(A) The Motion of Translation. — A projectile fired from a gun is 
acted upon by three forces: the force of discharge, or of explosion, 
which sets the projectile in motion; the air resistance, which opposes the 
motion of the projectile and which is therefore a retarding force; and 
the force of gravity, which tends to deflect the projectile toward the 
center of the earth. Brief consideration will be given to these forces, 
the effect of each separately on the projectile, and the resultant of 
their combined effects. 

(1) The Force of Explosion. — The force of discharge is due to the 
explosion of the powder with which the gun is charged. This explosion 
is a chemical action between the constituent elements, which liberates 
gas and generates heat. A certain amount of powder will, when sub- 
jected to this chemical action, liberate a certain volume of gas, generate 
a certain amount of heat, and sometimes form a certain amount of 
solid matter or residue. Modern smokeless powder leaves practically 
no residue. The gas, being at a high temperature and confined to a 
small space, will exert a high pressure on the walls of the gun and upon 
the base of the projectile. The walls and the breech of a gun are de- 
signed to withstand the powder pressure, so that the expansive force of 
the powder gas can be expended only in driving the projectile from the 
gun. The projectile, therefore, leaves the bore of the gun with a 



BALLISTICS 25 

certain muzzle velocity, and for similar guns, similar projectiles, and 
equal powder charges, this velocity will be the same. 

Slightly beyond the muzzle of the gun the powder gases cease to 
act on the projectile, and it moves forward with a certain velocity, 
which according to the laws of physics, would remain constant if 
there were no air resistance, or retardation due to any other medium, 
and no force of gravity; the projectile would then continue to travel 
indefinitely into space at a constant velocity. 

(2) Air Resistance. — The effect of air resistance on the velocity of 
a projectile has been the subject of diligent research. From the time 
of Benjamin Robins and his experiments with the ballistic pendulum 
and the whirling machine, in the year 1742, to the experiments of Bash- 
forth and Mayevski, in the latter part of the nineteenth century, with 
modern projectiles at high velocities, and to our own test and proof fir- 
ings at the ordnance establishments, the science of exterior ballistics 
has been developed and improved to such a degree that the path of a 
projectile can be calculated with remarkable accuracy. From these 
experiments expressions have been deduced for the retardation due to 
the air in terms of constants depending upon the form of the project- 
ile, of constants depending upon the velocity of the projectile, of fac- 
tors of the velocity, and of factors depending upon the atmospheric 
condition. The retardation of the sharp-pointed bullet used in the 
United States rifle, caliber .30, model of 1903, or the rate at which its 
velocity is decreased, is calculated to be about 2100 feet per second 
while the bullet has a velocity of from 2600 to 2700 feet per second, 
about 850 feet per second while it has a velocity of from 1370 to 1800 
feet per second, and about 18 feet per second while it has a velocity 
below 790 feet per second. These figures show that at the higher 
velocities air resistance is a factor of great importance. 

It is seen, then, that a large portion of a projectile's energy 
is expended in overcoming the air resistance, that the resistance is 
greatest during the period at which it maintains a high velocity, and 
that were there no force of gravity to draw the projectile to earth the 
projectile would travel in a straight line but with a variably decreasing 
velocity until finally it came to rest at an infinite distance from the gun. 

(3) The Force of Gravity. — Gravity is the force that attracts all 
bodies toward the center of the earth. It is a continuous force, and 
therefore an accelerating force. That is, if it acts on a free body one 
second it will give that body a certain acceleration, and should it cease 
to act after the first second the body would continue to fall at a constant 



26 



GUNSHOT WOUNDS 



velocity, neglecting air resistance; but the force continues to act 
through the second second and every following second, giving the 
body the same acceleration each second. The acceleration due to 
gravity is 32.16 feet per second; this value varying slightly with the 
latitude and longitude of the place. In vacuo, then, a body falling 
would have a velocity of 32.16 feet per second at the end of the first 
second, a velocity of 64.32 feet per second at the end of the second sec- 
ond, of 96.48 feet per second at the end of the third second, and so on, 
or the velocity v at any time would be equal to gt, the product of 
the acceleration and time. 

The height h through which a body would fall at a constant 
velocity equals the product of time and velocity vt. But a falling 




Fig. 10. 



body has a variable velocity, and it becomes necessary to find an 
average velocity. For a body starting from rest and falling at a con- 
stant acceleration, the average velocity is one-half its final velocity. 
Since we have seen that the final velocity is equal to gt, the height 
of fall, h, equals 1/2 gt 2 , one-half the product of the acceleration and 
the square of the time. Projectiles, therefore, are given an accelera- 
tion downward the instant they leave the muzzle of the gun. If the 
axis of a gun fired is horizontal, the projectile will have fallen 16.08 
feet below this axis at the end of the first second, 64.32 feet at the end 
of the second second, and 144.72 feet at the end of the third second, 
and so on. 

(4) The Combined Effect of the Forces. — Referring to Fig. 10, A, B, 
C, and D mark the distances a fired projectile will have traveled from 



BALLISTICS 27 

gun at the end of the first, second, third, and fourth seconds, respec- 
tively, neglecting air resistance and gravity. Under that assumption 
we have seen that the projectile would travel in a straight line at a 
constant velocity; therefore the intervals between these points are 
equal. But, due to air resistance, the velocity of the projectile is 
being constantly decreased, so that actually the projectile travels only 
to A' during the first second and only reaches points B' , C f , and D' 
at the end of the second, third, and fourth seconds. 

If, on the other hand, the projectile were dropped from the muzzle 
of the gun (Fig. 10), it would fall the distance Oa during the first 
second, to b during the second second, and to c and d during the third 
and fourth seconds, neglecting air resistance. But due to air resistance, 
it falls only to the points a f , b r , c f , and d f during those four seconds. 

Combining these two motions, the vertical and horizontal, to ob- 
tain the actual resulting motion (Fig. 10), we find that at the end of 
the first second the projectile will have traveled the horizontal distance 
OA' } but it will also have fallen the vertical distance Oa', so that 
actually it will have reached the point A". And similarly at the end 
of the following seconds, it will have reached the points B", C", enidD", 
and so on. Since the air resistance tends to bring the projectile to rest, 
and gravity constantly increases its velocity of fall, it is easily seen 
that, given the space, the projectile would tend to assume a vertical 
direction of motion. 

(B) The Motion of Rotation. — To keep the oblong projectile in 
its direction of travel, it is given a motion of rotation about its longer 




Fig. 11. 

axis. This rotary motion prevents the projectile from tipping when 
the resultant air resistance becomes oblique to the axis of the project- 
ile. Fig. 11 shows a projectile fired horizontally. It has a tendency 
to keep its axis parallel to the axis of the gun, and so long as the pro- 
jectile travels in a line with its axis, the resultant air resistance coin- 
cides with its axis. But the projectile takes a course downward; so 
that the resultant air resistance will make an angle with the axis and 
passing over its center of gravity will tend to tip the projectile. 



28 



GUNSHOT WOUNDS 



This rotation is caused by spiral grooves, called rifling, cut in the 
bore of the gun. As the projectile passes through the bore it engages 
with these grooves and is turned by them. The velocity of rotation 
of a projectile depends upon its linear velocity and upon the twist of 
the rifling. In the present . 30 caliber service rifle the twist is one turn 
in 10 inches. 



VARDS. 




B 



Fig. 12. 



But though the rotation prevents the projectile from tipping, it 
causes it to deviate from the vertical plane of fire. This deviation is 
called drift. There seems to be a difference of opinion as to the cause 
of drift, whether it is a gyratory effect, or whether the projectile tends 




Fig. 13. 

to roll on the more dense air beneath it; suffice it to know that it is 
due to air resistance. The drift of a gun is in the direction of its rifling, 
a right-handed twist causing a drift to the right, and vice versa. 

Figure 12 shows the drift curve, up to 2000 yards, of the present 
caliber .30 service rifle. AC is the path of deviation of the projectile 
from the vertical plane AB. 



BALLISTICS 



II. THE TRAJECTORY 



29 



The curve described by the center of gravity of a projectile during 
its passage through the air is called the trajectory. In vacuo a trajec- 
tory would be a parabola, but the curve is greatly deformed from that 
of a parabola by the air resistance. Fig. 13 shows the trajectories of 
the caliber .45 Springfield rifle, the Krag-Jorgensen rifle, and the 
present caliber .30 service rifle at a range of 1000 yards. 

(a) The Danger Space. — Fig. 14 shows the 1000-yard trajectory of 
the service rifle. The line DE is drawn horizontally a distance of 8 




feet above the ground line OX, representing the height of a cavalryman, 
the line FG is drawn similarly 68 inches above the ground to represent 
the height of an infantryman. The points/, d, e, and g are projections 
of the intersections of these horizontal lines with the trajectory. It 
will be seen that a man on horseback will be in danger in the fields Od 




100 



700 YARDS 



Fig. 15. 



and eX, while a man standing will be in danger in the fields Of and gX. 
The danger space is the territory in which objects are liable to be hit. 
Fig. 15 shows the cavalry and infantry danger spaces for the 700- 
yard trajectories of the caliber .45 Springfield rifle and the service 
rifle. The danger space of the former is quite short, while that of 
the latter is continuous. The flatter the trajectory the greater will 
be the danger space at the long ranges, as shown in Fig. 13, and the 
greater will be the continuous danger space, as shown in Fig. 15. 



30 GUNSHOT WOUNDS 

In order to increase the effectiveness of rifle fire, the construction 
should be such as to give the flattest possible trajectories. Fig. 13 
shows the development in that direction in this country. 

(b) Factors that Affect the Trajectory. — The curvature of a tra- 
jectory is primarily due to gravity. It is obvious that if two guns are 
fired horizontally, their projectiles traveling at such velocities that 
the first will reach a 1000-yard target in one second, the other the same 
target in two seconds, the former will, at the target, have fallen 16.08 
feet below the horizontal plane through the muzzle of the gun, while 
the latter will have fallen 64.32 feet. The projectile traveling fastest 
will have the flatter trajectory. In order to obtain a flat trajectory, 
therefore, it is necessary to have a high muzzle velocity and a low air 
resistance. 

The muzzle velocity of a projectile depends mainly upon the charge, 
the pressure, and the weight of the projectile, and is limited by the allow- 
able energy of recoil and the attainable strength of the gun. The 
weight of a rifle must not be excessive, its recoil must not be too great, 
and the bullet must not be too light, lest it have insufficient stopping 
power. 

(c) Sectional Density and Form. — While it is important to improve 
the interior ballistics of a gun in order to obtain a high muzzle velocity, 
it is equally important to reduce the air resistance. The formula 

d c 
R = A n ^-' i i 2 V n is an expression for the retardation in feet per second 

due to the resistance of the air. A n is a constant depending upon the 
velocity of the projectile, obtained from a ballistical table; V is the 
velocity of the projectile in feet per second and n is a number depend- 

ent on the velocity considered, *- is an atmospheric correction ob- 
tained from a table and is the ratio of standard density of atmos- 
phere to the density of atmosphere at time of firing; and "c" is a 
form coefficient determined by experiment. The term w/d 2 is the sec- 
tional density of a projectile, and is its weight in pounds divided by the 
square of its diameter in inches. From the formula it will be seen that 
the greater the sectional density the less will be the retardation. 

In order, then, to improve the trajectory by reducing the air resist- 
ance, it is necessary to increase the weight of the projectile and to 
decrease its diameter. A projectile's weight, however, is dependent 
upon the muzzle velocity desired and the recoil of the gun permitted, 
so that the sectional density can be improved mainly by decreasing the 
diameter. The diameter, on the other hand, it must be remembered, 



BALLISTICS 



31 



affects the destructive capacity of the projectile and in small arms 
projectiles the shock effect. 

The air resistance can be further reduced by improving the pro- 
jectile's form. Fig. 16 shows the relative resistance of spherical-headed 
and ogival-headed projectiles. The resistance to the ogival head 
struck with a radius of two diameters is taken as unity. The resist- 
ance to a spherical head is a fourth greater, while that to the ogival 
head of 7 diameters radius is only about half as much. In addition 
to pointing projectiles, experiments are under way with rifle bullets 
to determine the effectiveness of a rear ogive with a view to still further 
reduce the retardation due to the air. In the formula above the effect 
of a projectile's form on the retardation is expressed in the term u c" 
which is determined experimentally. 



n 



A 



A 



RADIUS ±= ^0 
RC515TAMCt= LS7 



ID 
1.0 S 



2D 
100 



3D 
82 

Fig. 16. 



4D 
71 



5D 
.64 



6D 
.58 




THE UNITED STATES OR NEW SPRINGFIELD RIFLE 

The present service rifle was adopted in 1903 on the recommen- 
dation of a board of officers, after exhaustive tests. The important 
changes that have been made in the rifle since its adoption are given 
below. The rear sight on the rifle as adopted was replaced by an 
improved sight in 1905. Experiences in the Russo-Japanese War 
showed that it was essential for an infantryman to have a serviceable 
bayonet, and as a result the rod bayonet was displaced in 1905 by a 
long knife bayonet. In 1906 a sharp-pointed bullet was adopted and 
a pyrocellulose powder substituted for the nitroglycerin powder. 
These changes resulted in an increased range, a flatter trajectory, 
and a longer accuracy life due to decreased erosion. To accommodate 
these changes a slight alteration was made in the chamber of the rifle. 

UNITED STATES RIFLE, MODEL OF 1903 

Weight without bayonet 8 . 69 pounds. 

Weight with bayonet 9 . 69 pounds. 

Capacity of Magazine 5 cartridges. 

Rifling, uniform twist, one turn in 10 inches, right hand. 

Sighted from 100 to 2850 yards. 

Diameter of bore 30 inch. 



32 



GUNSHOT WOUNDS 



BULLET, MODEL OF 1906 

Length 1 . 095 inches. 

Maximum diameter 3085 inch. 

Weight 150 grains ± 1 grain. 

Material of core 96 . 7 per cent, of lead and 3 . 3 

percent, tin, approximately. 
Jacket Cupro-nickel , 85 per cent, cop- 
per and 15 per cent, nickel. 
Charge, pyrocellulose powder, determined for each 

lot of powder, ordinarily about 48 grains. 

Muzzle velocity of bullet 2700 feet per second. 




U. S. Model of 1903 
Cartridge. 



U. S. Model of 1906 
Cartridge. 



Fig. 17. 



Fig. 17 shows the difference between the model of 1903 and model 
of 1906 cartridges. All U. S. Army rifles have now been chambered 
for the latter cartridge. 

The rifle has a right-hand twist, and the drift is therefore to the 
right. Due to a slight lateral jump to the left, the trajectory is found 
to be very slightly to the left of the central or uncorrected line of sight 



s 



BALLISTICS 33 

up to a range of 500 yards, and beyond that range it is to the right 
of this line. The drift at 1000 yards is 13 inches to the right, and 
at 2000 yards about 12 feet. The drift slot on the rear sight leaf is 
so cut as to partially correct for the drift. 

The English and German armies are equipped with reduced caliber 
rifles which fire the pointed bullet. The German bullet is composed 
of a single lead core enclosed in a casing of cupro-nickel-steel very 
similar to that used by the United States Army. The English bullet 
is also a compound bullet but it is composed of a double core, made up 
of two metals. The forward core measures 11 mm. in length, com- 
posed of aluminum, and the rear core is 20 mm. in length, composed 
of a lead core separated from the forward core by a narrow line of 
demarkation. 

The French service has a pointed bullet also, made up of one solid 
mass of bronze (90 per cent, copper). It is longer than any of the 
pointed bullets. On account of its sectional density, its stability is 
better maintained in the extreme ranges, it does not fragment so 
readily as the compound bullet, and the wounds it causes are not, 
generally speaking, of such a mutilating character at proximal ranges. 

Recent successes in the Pan-American, Olympic and Palma com^" 
petitions demonstrate that we have the most accurate rifle in the world. 
With a high muzzle velocity and a flat trajectory, little remains to 
be desired in the present rifle unless the trajectory can be further 
lowered and the continuous danger space for a height of 68 inches 
extended from the present range of 730 yards to a range of 1000 yards. 

The automatic rifle will, no doubt, be the military weapon of the 
future. All nations have experimented with rifles of this type, but 
so far as is known no nation has succeeded in finding an automatic 
rifle sufficiently reliable and effective in the hands of troops to justify 
the expense of adopting it in place of the rifles now in use. In 1909 
the Mexican Government ordered 4000 Mondragon automatic rifles. 
This gun uses the same cartridge as the Mauser rifle with which the 
Mexican troops are armed. 

The following table shows the different features of the reduced 
caliber rifles now in use by the armies of the world. 







1/ 



CHAPTER II 

The Characteristic Lesions Caused by Projectiles 

Wounds by Projectiles from Hand Weapons. — No chapter of 
surgery has undergone such radical changes as that pertaining to gun- 
shot wounds. The wounds from firearms have received benificence, 
like all wounds, from modern methods of treatment; but aside from 
this, wounds from weapons like the military rifle are not at all times 
so extensive in their pathological characters as they were formerly, 
and they are more amenable to treatment. 

To understand the characteristic appearances of bullet wounds in 
general, we will first consider the effect of the old-time, larger, and lower 
velocity projectiles, as compared to those of more recent times. 

The Old Round Balls. — These were usually composed of soft 
lead under the name of musket balls of about .72 to .75 calibers, 
having an initial velocity of 600 to 767 f.s. With these low 
velocities, spherical balls showed destruction of an amount of tissue in 
soft parts coincident with the diameter of the projectile. The mechani- 
cal effects of such a bullet were more that of stretching the tissues to 
permit the passage of the missile. The wound of entrance was round, 
the size of the bullet, with a punched-out appearance, and it was sur- 
rounded by a more or less extensive ecchymosis. The track of the 
bullet was identified by a channel of devitalized tissue greater than the 
diameter of the ball. The exit wound in the skin was always greater 
than the entrance wound, triangular or star-shaped, with everted 
edges having the appearance of an injury inflicted by a force exerted 
from within. 

The effects of the old spherical bullet on bone were marked by lodg- 
ment in a large proportion of the cases, and flattening of the projectile 
itself. When propelled by its maximum velocity of translation, the 
bullet was capable of causing extensive damage, though less than that 
observed from the conoidal rifle bullets of a later date. The force of 
impact caused extensive comminution, with displacement of spicule 
about the line of flight of the bullet. Fissures were seen in the shaft 
above and below the area of fracture. This bone lesion, added to the 

34 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 35 

extensive trauma in soft parts, made the gunshot wounds of that 
era prone to suppuration and dangerous to life. 

The Cylindro-conoidal Bullet. — The use of elongated bullets was 
coincident with the adoption of the hand rifle. The earlier types were 
fired from the Minie rifles, so-called, and later as the guns became more 
perfect, the initial velocity was increased accordingly. The accom- 
panying chart gives the ballistic data and development stages of old- 
time, and modern firearms used in war. 

The wounds by the elongated bullets, from the beginning, caused 
enormous destruction of tissue, and as the arms from which they were 




Fig. 18. — Lodged spherical soft-lead ball. Amputation lower third thigh. No. 4063 A. M. 
Museum. Specimen from Civil War, 1861-65. 

propelled became more and more perfect, the severity of the wounds 
increased so markedly that accusations and recriminations of the use 
of explosive bullets were commonly made by combatants in the 
beginning of every war. The pathological appearances of a gunshot 
wound of the shaft of a long bone, were so much like the destruction 
wrought by a hollow bullet loaded with an explosive, that it was not 
until the mechanics of the projectiles had been properly understood 
that a satisfactory and convincing explanation of their effects was 
made. 

The aim of the ballisticians, in perfecting the military rifle, from 
the beginning was directed toward an increase in the velocity of the 
projectile. This was done by accomplishing a perfect fit of the pro- 
jectile in the barrel to prevent the escape of powder gases. The effect 
of this plan on the large calibers in use at the time of the transition, 



36 



GUNSHOT WOUNDS 



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CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



37 



from the smooth bore to rifle weapons, was to add immensely to the 
recoil. The latter became such a tax on the soldier's endurance that 
it was necessary to reduce the caliber and the amount of the explosive 
as well. Increase in velocity and reduction in caliber materially added 
to the penetration of bullets. The wounds produced in soft parts 
were not attended with so much contusion and laceration as with the 
use of the old spherical balls. The amount of devitalized tissue sur- 
rounding the track was less — the wound was more clean cut as it were. 
Bone Injuries by the Cylindro-conoidal Bullets. — When a 45 cali- 
ber bullet or a projectile from any of the larger caliber rifles mentioned 





Fig. 19. — Lodged conoidal ball, radiating 
fracture. No. 3175 A. M. Museum. Speci- 
men from Civil War, 1861-65. 



Fig. 20. — Lesion by conoidal ball. 
From amputated limb. No. 3245 A. M. 
Museum. Specimen from Civil War, 
1861-65. 



happened to collide with a resistant bone, like the diaphysis of the 
humerus or femur, the destructive appearance, as already stated, 
resembled the effects of an explosion having taken place from within 
and the pathologic condition was generally described in the literature 
of gunshot wounds under the term of Wounds Having Explosive Ef- 
fects. The characteristic lesions were notably seen in the proximal 
ranges — from the muzzle up to about 350 yards. Except for close 
shots at contact or nearly so, the wound of entrance presented no 
special features. When it was located in skin overlying bone, as over 



v x 38 



GUNSHOT WOUNDS 



the tibia, bony sand was noted at the wound of entrance in a cer- 
tain proportion of the cases. The point of impact against resistant 
bone shewed loss of substance, the bone was finely comminuted, and 
radiating from this point larger spiculse of bone, some entirely de- 





Fig. 21. 



Fig. 22. 



Fig. 21. — Caliber .50 conoidal bullet lodged against plantar surface right foot. Partial frac- 
ture of cuboid and cuneiform bones. Primary amputation by Chopart's method. Died ninth 
day of typhoid fever. No. 6531 A. M. M. Specimen from Civil War, 1861-65. 

Fig. 22. — X-ray print of left leg of a Civil War (1861-65) veteran showing lodged large caliber, 
soft lead, fragmented bullet, lying between tibia and fibula anteriorly just below superior fibulo- 
tibial articulation, where it can be easily palpated. Missile entered leg posteriorly in median line of 
calf, about 3 inches below knee-joint and passed directly forward, apparently without seriously 
injuring the bones and lodged anteriorly as shown. The bullet was fragmented by bony contact 
in its passage through the leg. Endeavor was made on the battle field to extract the bullet by the 
fingers passed through the wound. Wound was infected and discharged pus for three or four months 
Since healing of parts there have been no symptoms of pain, atrophy, etc. Exposure made in 1912. 
Army Med. School collection. H. F. Pipes, Capt., Med. Corps, U. S. A., X-rayist. 

tached, were driven into the soft parts in the line of flight of the bullet 
and at right angles to the direction of the moving body. Pulpification 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



39 



of soft parts was noticed at some distance from the track of the 
bullet, as a result of the penetration and laceration by particles of 
bone, and as often happened, disintegrated particles of the, bullet 
which, taking part of the projectiles' energy and acting as secondary 
missiles, added to the destructive effects. The wound of exit was 
irregular, and measured as much as 3 and 4 inches in its longest 
diameter. The space from the wound of exit to the point of impact 
on the bone was conical in shape, with the base of the cone correspond- 




Fig. 23. — Recent skiagram in case of Maloy W. Rock, Co. "C, " 1st Va. Cavalry. Shot by 
conoidal bullet in Civil War, 1864. Some pain in region of bullet not enough to prevent him 
from his usual work. X-ray Laboratory National Home for D. V. S., Marine Barracks. 



ing to the wound of exit, and the apex to the seat of fracture. There 
was usually more or less Assuring of the shaft radiating from the 
fractured ends. Beyond the zone of explosive effects fragmentation 
was not so marked, there was absence of bony sand; the fragments were 
not so much displaced. The wound of exit was, however, perceptibly 
larger than the wound of entrance and this fact was, as a rule, a pretty 
sure indication of bone lesion. 

When the conoidal bullets happened to collide with the epiphyseal 
ends of the long bones in the proximal ranges the softer bone was 
broken into many fragments, with less tendency to displacement of 
fragments than noted in the more brittle osseous structures. There 



40 



GUNSHOT WOUNDS 



was more bone dust and greater tendency to entire loss of substance 
at the point of impact, with little or no Assuring of the shaft. At longer 
ranges — 500 to 1500 yards — the bullets showed a tendency to perforate 
the epiphyseal structure with no splinters nor fissures resulting. The 
pathologic lesion was a complete perforation, resembling a hole made 
by a drill. The cause of the difference in the lesion noted between the 




Fig. 24. — Anterior and posterior views. Fracture at base of trochanters. Note long fissures. 
Lodged deformed conoidal ball. No. 87, A. M. M. Specimen from Civil War, 1861-65. 



middle of the shaft and the joint end of a long bone lay in the degree of 
resistance offered — the bone of the shaft being hard and more brittle, 
that of the epiphysis being soft and spongy. 

The amount of destructive effects in bone was always coincident 
with (a) resistance on impact, (b) sectional area of the bullet and (c) 
its velocity. The theories advanced to explain these so-called explo- 
sive effects will be taken up later. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



41 




Fig. 25. — Anterior and posterior views of fracture right femur from conoidal ball. Amputation 
third day; died nineteenth day. No. 2056 A. M. M. Specimen from Civil War, 1861-65. 




Fig. 26. — Perforation by musket ball of epiphyseal end right femur with long fissures in shaft. Limb 
amputated; death on fourteenth day. No. 76, A. M. M. Specimen from Civil War, 1861-65. 



42 GUNSHOT WOUNDS 

Injuries by Steel Armored Bullets from Reduced Caliber Rifles. — 

Our first knowledge of the effects of steel-clad bullets came to us from 
certain experiments. The experimenters were at the outset con- 
fronted with the difficulty of hitting one particular anatomical part 
— the femur or tibia for instance — at anything like battle ranges. 
Obviously experiments at the actual ranges must have consumed 
much time and material, and observers in the experimental field 
followed the plan, which is common with gun makers in like cases, of 
employing simulated ranges, i.e., by regulating the charge in such 
amount as to confer the remaining velocity which might be required 
at any given distance. In a series of experiments which we conducted 
at Frankford Arsenal, Philadelphia, in 1893, we fired into cadavers at 
a fixed distance of 53 feet, and from this distance, by graduating the 
charge, we were able to note the effects of bullets on different 
parts of the human body at all ranges from 100 to 2000 yards. 

The results which were thus obtained were subsequently criticised 
from many quarters. It was claimed that the experimental shots 
against bone and closed cavities containing fluid contents gave ex- 
aggerated results as compared to what was seen in war subsequently. 
Some of the critics attributed these discrepancies to the use of dead 
tissues as compared to the effects of the same projectiles on the living, 
and, again, it was claimed that the velocity of rotation of the elongated 
bullets was different in the shots at simulated ranges as compared to 
what it would be at normal ranges. 

In addition to our own experiments with this method, Delorme and 
Chavasse in France, Kocher at Berne, Paul Bruns of Germany, and 
others, employed the method which we pursued. The conclusions 
arrived at independently by the experimenters were, practically, 
-the same. They related principally to the humane features of the 
wounds caused by the new bullet on some tissues, and the explosive 
effects noted on others, but, generally speaking, the bullet was looked 
upon as likely to play the part of a humane instrument in the wars of 
the future. 

Later, Demosthen, von Coler, Schjerning and others shot into 
cadavers with full charges at actual ranges and they arrived at differ- 
ent conclusions to those of the observers who had shot at simulated 
ranges. They claimed that the explosive effects at the proximal 
ranges were less with the use of normal charges, and that the destruc- 
tive effects became perceptibly less as the range was increased. 

In recent years the results from the Spanish-American, Boer, 
Russo-Japanese and the recent Turko-Balkan wars have come up for 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 43 

comparison with the work of the experimenters. The war wounds are 
thought by some critics to be but little different from those obtained 
from experimental shots, while quite a number of the critics arraign 
the experimenters who would use simulated methods on putrid flesh 
as rank exaggerators. We will endeavor to show that the work of the 
experimenters was not done in vain. By comparing photographs, 
dissections, and skiagrams of gunshots on cadavers at simulated ranges 
with similar illustrations obtained in recent wars, we hope to show 
that the conclusions of the experimenters were in the main correct. 

While visiting at Val de Grace one day in 1900 the writer saw an 
improvised target in a corner of the enclosure. He afterward saw a 
student dissecting a gunshot fracture of the tibia in a cadaver and on 
inquiry he was told by Surgeon General Dujardin Beaumetz that the 
method of firing into dead bodies for the purpose of teaching the ef- 
fects of gunshots in war had been practised in the French Army for 
one hundred years. Surgical literature gives the French Army 
surgeons the front rank as writers on Military Surgery, and it is not 
reasonable to suppose that close observers, such as they have shown 
themselves to be, could pursue a method so long when, as some critics 
would have us believe, there is nothing to be learned from it. 

We are willing to concede that a dead body half frozen out of cold 
storage, hardened in pickle; or, a fleshy body, stiff in rigor mortis, 
will give exaggerated results in shot fractures of the diaphyses of the 
long bones. The rigid or plastic flesh offers more resistance and the 
wound of exit is doubtless larger and more lacerated, but in fit sub- 
jects, the effects on bones, the head, the chest, abdomen and vessels 
will compare with those on the living sufficiently to enable one to form- 
ulate conclusions that in the main are correct. The class in operative 
surgery in the U. S. Army Medical School is made to amputate for 
gunshot fractures and to examine by dissection the lesions in gunshot 
injuries in various parts of the dead body. This part of the work is 
always compared at the time with the X-ray findings which have been 
previously made in each case. 

From observations and experience off and on in the last twenty- 
one years by firing experimentally into cadavers, animals, and inan- 
imate matter, and later from opportunities which have come to us to 
see the comparative effects of the old and new armaments on the living 
in peace and war, we believe that the experimental way is the best 
method of teaching the mechanical effects of projectiles on tissues in 
times of peace at least, and that it answers as a valuable guide to a 
correct understanding of the gunshot injuries observed in war. 



44 



GUNSHOT WOUNDS 



Our experiments at Frankford Arsenal were conducted under 
orders of the War Department dated July 20, 1892. A board of 
officers was appointed of which the writer was the medical member, 
to ascertain the " effects of small arms firing with new calibers and 
velocities on the human frame." In order to make the results more 
apparent, the board followed the plan of. — 

(1) Noting the effects of a projectile of larger caliber and lower 
velocities upon different parts of the human body at various ranges. 

(2) Noting the effects of the projectile of a reduced caliber rifle, 
having greater velocities, upon similar parts of the human body or parts 
offering about the same resistance at similar ranges. 

The larger weapon selected was the .45 caliber Springfield rifle which 
had formed the armament of our foot troops since 1873 and which 
compared as to caliber, weight of ball, charge of powder, and ballistic 
details to the Gras, old Mauser, and the military rifles of the nations 
before the introduction of the new armament. 

The smaller caliber weapon furnished the board by the Ordnance 
Department was known as the Experimental Springfield rifle, caliber 
.30. Its bullet was impressed by 37 grains of Payton smokeless pow- 
der. This gun compared favorably with the rifles of reduced caliber 
in use at that time by Germany, France and Austria, viz., the Lebel, 
New Mauser, and Mannlicher. 

The more important ballistic values of the two weapons are set 
forth in the following tables: 



VELOCITIES OF THE PROJECTILES OF THE TWO GUNS 



Name and caliber of weapon 


Initial 
velocity 


500 

yards 


1000 
yards 


1500 
yards 


2000 
yards 


Springfield, caliber .45 

Experimental Springfield, caliber .30 


f.s. 
1301 
2000 


873 
1103 


676 

804 


531 

627 


429 
495 



A tackle was provided to suspend the cadavers and to bring the 
portion of the body to be fired at into proper position. Each projectile 
was stamped at the base with a letter or number for identification and 
all bullets were collected from barrels of sawdust placed behind the 
target. Ten years after the termination of these experiments we went 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



45 



ENERGY OF THE PROJECTILES 

(In foot-pounds) 



Name and caliber of weapon 



Initial 
velocity 



Weight 



Muzzle 



500 

yards 



1000 

yards 



1500 

yards 



2000 
yards 



Springfield, caliber .45 

Experimental Springfield, 
caliber .30. 



f.s. 


Grains 










1301 


500 


1879 


846 


507 


313 


2000 


220 


1954 


594 


315 


192 



204 
120 



to war with Spain; the wounded from this war gave the first oppor- 
tunity of any consequence to military surgeons to observe the effects 
of reduced caliber bullets on the living. Before this we had depended 
upon accidents, suicides and reports from some of the South American 
revolutions, but the latter especially were meager and unreliable. 
In the battle of Santiago the United States troops engaged numbered 
about ten thousand men, those of the enemy approximately the same. 
Our casualties were 233 killed and 1400 wounded. Having taken 
active part in the experimental work already referred to, the writer 
was necessarily very much on the alert to compare the wounds on the 
living in war with those he had so often witnessed on the dead in peace. 
We had occasion at this time to review our own conclusions, and those 
of other experimenters, with the experience culled in and after the bat- 
tle of Santiago. The conclusions of the experimenters are 12 in num- 
ber, and they appear in quotation marks with a running comment, as 
follows: 

(1) The experimental evidence showed that "the shock impressed 
upon a member increases with the velocity, whether a bone is traversed 
or not. It is always greater with the larger caliber leaden project- 
ile." This diminution in shock has been one of the serious objec- 
tions advanced against the adoption of the small bullet by military 
men. They feared that one wound would not suffice to throw a man 
hors du combat, and that he might be able to go on fighting regardless 
of the fact that he had been hit a number of times. Whether this 
is true of savage tribes, or horses in a cavalry charge, it is not true 
of our American soldiers. Upon inquiry among line officers in the 
Santiago campaign, we learned that, as a rule, to which there were very 
few exceptions, men when hit fell back to the rear at once; and we can 



46 



GUNSHOT WOUNDS 



testify to the fact that scores of them walked back to our hospital 
at Siboney, with wounds that were most trifling in their nature. 

(2) "The explosive effects at very short ranges are about the same 
for the two projectiles and they continue so up to about 350 yards." 
We only saw one case which approached anything like explosive effects 
in Cuba. That was the case of a captain of the rough riders, shot in 
the lower third of the tibia. The wound of entrance was about the 




Fig. 27. — Two views of explosive effects from Mauser bullet at close range at battle of Santiago. 
Radiograph one year after injury. Army Med. School collection. 



caliber of the Mauser bullet that had inflicted it, and the wound of 
exit was irregularly round, a half-inch in diameter. There were two 
smaller wounds near the wound of exit, which were undoubtedly made 
by spiculse of bone which had been driven forth, acting as secondary 
missiles. The area of fracture was about 4 inches above the ankle; 
it was marked by a cavity in which many loose fragments of bone lay, 
none of them measuring more than a half-inch. The wall of the cavity 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



47 



showed bony sand driven into the soft parts. The infrequency of 
explosive effects among the wounded at the battle of Santiago should 




Fig. 28. Fig. 29. 

Fig. 28. — Photograph of a butterfly fracture of tibia; experimental specimen from cadaver 
by the reduced caliber bullet at 1200 yards. The fissures were mostly subperiosteal in recent 
specimen. Army Med. School collection. 

Fig. 29. — (1) Guttering of tibia and transverse fracture from vibratory force by reduced caliber 
bullet at 1200 yards. Experimental specimen, from cadaver. (2) Complete perforation of lower 
epiphyseal end of tibia with slight Assuring, same ammunition as No. 1 and at the same range. 
Bullet replaced in perforation by photographer. Army Med. School collection. 

be attributed in our opinion (a) to the fact that the vast majority of the 
wounds were inflicted beyond the zone of explosive effects, and (b) 



48 



GUNSHOT WOUNDS 



since explosive effects are chiefly to be noted in the vital parts con- 
tained in rigid walls, like the brain, or in those organs containing much 
fluid, like the heart, liver, spleen, the alimentary tract, these wounds 
with explosive effects, so destructive to tissue, were numbered among the 
dead — a class which, unfortunately, the surgeon has no time to study 
on the battle field (Fig. 27). 

(3) The experimenters found that "the smaller frontage of the 
jacketed bullets causes them to inflict injuries resembling subcutaneous 
wounds when the soft parts alone are traversed, and that the small 




Fig. 30. — Photograph of perforation in head of tibia by .30 cal. German silver-jacketed bullet, 
shot out of the experimental Springfield rifle, into a cadaver at a simulated range of 1200 yards by 
the author. Bullet used is undeformed and shows to left of specimen, (a) Orifice of entrance; (b) 
orifice of exit. Army Med. School collection. 



wounds of entrance and exit and the narrow track of the missiles were 
favorable circumstances to rapid healing." The truth of this state- 
ment is borne out by the experience of all surgeons in the Santiago 
campaign. Flesh wounds healed very kindly and rapidly. 

(4) This conclusion of the experimenters refers to hemorrhage. 
Johann Habart, of the Austrian Army, who paid special attention to 
this subject, states "that the blood-vessels are seldom torn by the 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



49 



small jacketed bullet, and that when wounded they are not closed so 
easily by coagulation as those severed by leaden projectiles." Some 
writers have deduced from this statement that alarming or fatal 
hemorrhage would be more frequent in future battles. The experience 
of the surgeons with the line before Santiago does not confirm these 
apprehensions. Of the 1400 wounded as far as we could learn, not one 
died of external hemorrhage. The brachial and femoral were tied a few 
times in the base hospitals for diffuse aneurysm. One case of wound 
of the subclavian was operated upon in New York and died and there 




Fig. 31. Fig. 32. 

Fig. 31. — Front view. Radiograph in case of W. K. showing perforation of upper end of 
tibia. Wounded June 25, 1899, by a Krag-Jorgensen bullet at a distance of 10 feet. Radiograph 
taken 30 months after injury. Remote effects: slight weakness and pain at site of wound. Good 
motion in joint. U. S. Soldiers Home collection. 

Fig. 32. — Skiagram showing side view of Fig. 31. 



were five cases of gangrene from injury to blood-vessels which required 
amputation. 

(5) "Injuries inflicted outside the zone of explosive effects upon 
the shafts of the long bones always show less comminution with the 
small bullet of hard exterior. The fissures are often subperiosteal, and 
the fragments are larger." This was true of the Mauser bullet wounds 
in Cuba. It was seldom necessary to open up the wounds for the pur- 
pose of taking out loose fragments of bone. In a number of instances 
there was distinct guttering of the compact substance of long bones 



50 GUNSHOT WOUNDS 

without fracture. The mobility in some instances was so slight 
that it was difficult to make out a complete fracture when from the 
location of the wounds it was certain that the bone had been traversed. 
(6) " Beyond the zone of explosive effects the projectiles of hard 
exterior almost invariably perforate or gutter the joint ends of bones, 
and the lesions of the articulations are never so grave. " This conclu- 
sion tallies exactly with what we saw in Cuba. We do not recall a 




Fig. 33. — Exit wound showing explosive effects on bone by Japanese rifle bullet at short range. 

Russo-Japanese War. (Lynch.) 

formal excision of a joint for the mechanical effects of the Mauser 
bullet. Joints were opened to turn out blood clots, and in one instance 
of the knee we particularly remember, to locate a lodged ball, but 
never for the purpose of performing an excision. There were seventeen 
cases of gunshot injury to the knee-joint. These were immobilized 
and shipped north; and 82 per cent, of them were restored to duty 
within a few months. These results are a great contrast to gunshots 
inflicted by the larger leaden bullet, which by its highly destructive 
effects must have caused a number of partial resections and am- 
putations. 

(7) "The projectiles of hard exterior lodge less frequently in the 
tissues than the old leaden bullet." The experience at Santiago, 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 51 

among the wounded of both sides, has shown a surprisingly large 
number of lodged balls. Although we are not prepared to state that 
the small-caliber bullet lodges as often as the old discarded leaden 
bullet, the frequency with which it did lodge was commented upon 
by all of our military surgeons. Dr. W. E. Parker, of New Orleans, 
an acting assistant surgeon in the base hospital, visited the Spanish 
hospitals in Santiago after the surrender, and in conversation with 
the Spanish surgeons he learned that our Krag-Jorgensen bullet had 
not lodged in their wounded as often as their Mauser bullet had 
lodged in our men. The explanation for this would seem to be simple 
enough. It should be remembered that we were on the aggressive in 
a region that was practically unknown to our troops, while the 
Spaniards were perfectly familiar with every foot of ground over which 
we must make the advance. As trained soldiers, their officers had 
carefully studied the range at every point. With this valuable infor- 
mation in their favor they were in a position to commence an effective 
fire at remote ranges, say at 2000 yards and more. We could not locate 
them as soon as they located us, and when we did locate them, we had 
to study the range before we could commence an effective fire. It was 
while we were locating them and studying the range and gradually 
advancing that they placed so many balls into our soldiers. When 
we did commence an effective fire, we had reached a point where the 
remaining velocity of our bullet on impact was sufficient to carry it 
through the body. There is another explanation which might be at- 
tributed to the difference in the energy of the two bullets at remote 
ranges. Our bullet being larger and heavier than the Mauser has 
greater energy at 2000 yards, and it will penetrate farther in the remote 
ranges than theirs. Again, ricochet shots, from the thick underbrush 
and broken ground, undoubtedly favored a certain percentage of lodg- 
ments. Many of the officers attributed the lodgment of projectiles to 
the use of defective ammunition used by the enemy. This point was 
so susceptible of proof that we instituted experiments to show the rela- 
tive penetration of the Mauser and Krag-Jorgensen rifles. The tests 
were made in large blocks of well-seasoned yellow pine fired into, 
across the grain, <3 feet from the muzzle. The penetration of the 
Krag-Jorgensen ammunition was 24 inches plus, while that of the 
Mauser ammunition exceeded ours by nearly 10 inches, a demonstra- 
tion which at once set at rest the idea of lodgment from the defective 
ammunition of the enemy. 

(8) "The old leaden bullet more often leaves fragments of lead in 



52 GUNSHOT WOUNDS 

the foyer of fracture." This is so true that it needs no contradiction. 
The leaden bullet was so soft that it often separated into a number of 
fragments upon striking resistant bone, while the steel-jacketed bul- 
let, as is well known, seldom encounters resistance enough in the human 
body to disintegrate it. 

(9) "As the projectiles of smaller caliber are less apt to lodge or 
to carry foreign substances into the wounds, we will expect to find 
fewer cases of suffering due to the remote effects of unextracted foreign 
bodies." This is true of the smaller bullet, as shown in Cuba. There 
were but few instances where clothing or part of the equipment was 
carried into the wound. 

(10) "The frontage of the jacketed bullet being much less and the 
fact that it does not lodge as often as the larger leaden bullet will serve 
to increase the percentage of recoveries in gunshot wounds of the lungs." 
That was especially true of the wounded in Cuba. As a rule the 
wounds of the lungs were apparently so trivial that it was difficult to 
restrain the men in the recumbent posture. 

(11) "Owing to diminished frontage the new bullet will cause less 
disfigurements in wounds of the face." That was especially true of 
three officers who received painful wounds of the face. 

(12) "The projectiles of hard exterior are more humane than the 
old, resections and amputations will not be so often required here- 
after, soldiers will be more often restored to the State useful members 
of the community instead of cripples and pensioners, and in point of 
economy, the new projectile will confer a great advantage." This 
last conclusion is also in accordance with the experience in Cuba. 
There were but three primary amputations and not one of them was 
done for injury by the small bullet. They were all the result of shell 
injuries. From the foregoing we believe that the work of the experi- 
menters agrees with the conditions found in war, and that their work 
was not done in vain. Furthermore, we may slate that we are not 
acquainted with any experimenter who is ready to repudiate his work 
as futile. 

SOME FURTHER OBSERVATIONS ON WOUNDS BY MILITARY 

RIFLES IN RECENT WARS 

In the Spanish-American War the Spaniards were armed with 
the Spanish Mauser of 27.6-inch caliber, weight of projectile 172 
grains, with ogival head, and a muzzle velocity of 2296 f .s. The United 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 53 

States troops were armed with the Krag-Jorgensen rifle, of .30-inch 
caliber, weight of projectile 220 grains, with ogival head, and initial 
velocity of 2000 f.s. In the Boer War the latter were armed princi- 
pally with the Spanish Mauser, whose features are like those mentioned 
above, some Krag-Jorgensen and Martini-Henrys, but the bulk of 
the wounds came from their service weapon, the Spanish Mauser. 
The British troops used the Lee-Enfield of .303 diameter, with a muzzle 
velocity of 2060 f.s., weight of projectile 215 grains. In the Russo- 
Japanese War the Russians were armed with the Mossin-Nagant of 
. 30-inch caliber, with a muzzle velocity of 1985 f.s. ; weight of projectile 
214 grains. The first and second lines of Japanese troops were armed 
with a more perfect type of gun as follows: the Arisaka of 25.6 caliber, 
muzzle velocity 2390 f.s., weight of projectile 162 grains. The rest 
of their army was armed with a gun which corresponds to our Krag- 
Jorgensen of ten years ago. In the Turko-Balkan War of 1912-13, 
the Balkan states were armed with the Mannlicher rifle of reduced 
caliber which about corresponds to our Krag-Jorgensen rifle with the 
ogival-headed bullet used by our troops in the Spanish- American War. 
The military rifle of the Turks was the German Mauser, which fires 
the pointed bullet. This projectile was recently adopted by the Eng- 
lish and U. S. Armies. It was never used in campaign until the recent 
war between Turkey and the Balkan States. 

It will be seen therefore that the hand rifle of the combatants of 
all armies except the first and second lines of Japanese troops and the 
German Mauser of the Turks which fired the pointed bullet were the 
same in ballistic value. Taken as a whole there was no difference in 
the penetration or smashing effects of the bullets worthy of consider- 
ation with the possible exception of the 162-grain bullet of the Japanese 
Army, which was more humane and the pointed bullet of the Turks, 
in the recent Turko-Balkan War whose deadly effects will be com- 
mented upon later. 

Wound of Entrance — With high velocities the wound of entrance 
is apt to be larger than we find it at mid and remote ranges. The 
wound is round when the bullet strikes perpendicularly, and oval if 
it impinges obliquely. The regularity of the circle or oval is seen 
oftener in skin that is well supported. Entrance wounds in skin 
overlying bone as that over the sacrum, anterior part of tibia, and 
sternum, are larger than the projectile. In skin overlying loose areo- 
lar tissue like the scrotum, the entrance wound is less regular, slit- 
like, and apparently smaller than the diameter of the bullet. When 



54 GUNSHOT WOUNDS 

by ricochet or otherwise the bullet strikes side on or "butt end to" 
the entrance wound is irregular and lacerated. The edges of the wound 
are apt to be inverted or depressed for a short time, and covered with 
a dark gray substance, more than likely dirt, resulting from the gases 
of explosion. Underneath the dark stain appears the pink cuticle 
denuded of epithelium, by the friction of the projectile. This pink 
rim soon dries and turns brown in color. Slight ecchymosis appears 
later about the entrance wound, but it is never so well marked as in 
the case of the older and larger caliber bullets. 

Wound of Exit. — These wounds are more variable in extent and shape 
than the wounds of entrance. Again with maximum velocities, pro- 
vided no bone lesion is present, the exit aperture is often difficult to 
discriminate from the entrance wound. The two wounds may be 
equal in size, the entrance wound may show inverted edges, while 
in the exit wound the edges are generally everted. When the bullet 
has passed through soft parts alone, the exit wound is apt to be cir- 
cular in shape. In loose skin, with low velocities, the exit wound is 
apt to be lacerated, and when the velocity is high it is apt to be marked 
by a mere slit. The greatest extent of traumatism with maximum 
irregularity is seen in exit wounds following bone lesions. The lesion 
of hard bone, like the diaphysis at close range, shows maximum wounds 
of exit. Such wounds present typical explosive effects. The exit 
wound in the skin may be several inches in diameter. 

With the high-power military and sporting rifles the track of the 
bullet is marked by a straight line connecting the entrance and exit 
wounds when the parts have resumed the position of the body at the 
time of the shooting. The new bullet is seldom deflected. It goes 
in a straight line from the point of impact in the skin to the point of 
lodgment, or exit from the body. The bullet cuts a channel through 
soft parts, like muscle, the size of its own caliber or a trifle larger. 
The cylindrical track and the surrounding tissues are marked by the 
presence of hemorrhage, contusion, and engorged vessels. Perfora- 
tions in tendons and resistant fasciae are marked by circular or slit-like 
openings. When projectiles from richochet, or extended range, lose 
their balance, tendons may be torn across or lacerated as a result of 
keyholing. 

Foreign Bodies Carried in Wounds. — On account of the smaller 
frontage of the new military rifle bullet, particles of clothing, or part 
of the equipment of soldiers are not so often driven in wounds as they 
were by the projectiles of the larger caliber armament. Our ex- 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 55 

perience in Cuba and those of Makins, Stevenson and others in recent 
wars fully confirm this statement. The old-time larger caliber and 
lower-velocity projectiles carried foreign matter in wounds that proved 
a fruitful cause of prolonged suffering among the wounded. Among 
the particles carried in with the balls were portions of cotton and wool 
clothing, fragments of various articles found in the field kit of soldiers; 
also, coins, pieces of keys, watches, etc., carried in the soldier's 
pockets. Longmore even mentions bits of leather from boots, shoes, 
pouches, etc.; buttons, nails from shoes, buckles and other metallic 
substances which have from time to time been extracted from body 
wounds in the wars of the past. 

Injury to Blood-vessels. — As we have stated elsewhere injury to 
blood-vessels turns out to be one of the chief characteristic lesions of 
the new bullet. The projectile cuts the side of a vessel, or scoops out 
a hole in a large vessel, like a cutting instrument, leaving a band on each 
side of the openings. The cut edges are not lacerated and external 
hemorrhage or more frequently internal hemorrhage takes place at 
once. In the body cavities the hemorrhage is alarmingly fatal. In 
limbs or parts where the vessel is well supported by surrounding tissue, 
aneurysm is apt to follow. Vessels are no longer pushed aside as they 
were by the older lower-velocity bullets. 

Injury to Bone. — According to Fischer's well-known statistics 22 
per cent, of all gunshot wounds in war involve fractures of the long 
bones. Although his statistics were gotten out before the advent of 
the new armament we know that they are about the same for the wars 
of the present. A study of the effects of the new arm on the diaphyses 
of long bones of the extremities confirms entirely the work of the experi- 
menters. The Spanish- American, South African, and Russo-Japanese 
wars have given abundant evidence of the destructive effects of the 
small bullet on the compact substance of the long bones. These 
effects are magnified at short ranges or when the velocity is high. 

In our experiments referred to, we 1 called attention to perforations 
in diaphyses with subperiosteal fractures, which were incomplete, and 
to the great necessity of handling such bone lesions with care in order 
to prevent complete solution of continuity. Such lesions are more 
often seen in mid-range shots. This condition of perforation in the 
compact substance of a long bone has been noted in recent wars and 
it is to be accounted for as it was explained in the dissecting room by 
us, on the ground that bones are not of uniform resistance, the bones 

x Annual Report Surgeon General, U. S. Army, 1893. 



56 GUNSHOT WOUNDS 

of the young have more animal matter and they will sustain an injury 
which will simulate a perforation, while the bones of the older subjects 
have more mineral matter and being more brittle, they will show 
comminution by preference. 

Some observers have expressed surprise that extensive comminu- 
tion should take place in the latter end of the trajectory, at say 2000 
yards. This is true in war on the living and true of experi- 
mental shots on the dead. Up to 350 yards the destructive 
effect of the larger caliber lead bullet and the small-jacketed bul- 
lets are alike severe. Unless guided by the wound of entrance or 
other circumstances it is difficult within this range to determine by 
the appearance of the external wounds alone which of the projectiles 
may have caused the injury. Beyond this range the destructive 
effects of the smaller projectile become less than those of the 
larger missile. The Assuring is less, the spiculse of bone are 
larger, and they are more apt to be attached to the perios- 
teum. These differences are especially noticeable from the 500 
to the 1500 yard ranges. At 2000 yards the small bullet again shows 
rather extensive comminution. This fact has been noted by all 
observers, and it has been variously explained, though not in a very 
satisfactory manner. It has been said that the projectile has lost so 
much of its velocity of translation when it reaches this part of its course 
that it is apt to lodge, and that the velocity of rotation causes such a 
disturbance when it is about to engage that comminution is the result. 
The angle of impact, which is rarely perpendicular at this range, has 
also been brought forth as a possible cause. Certain it is that a number 
of the projectiles were observed at this range by us to impinge side 
on at the moment of impact. The results in recent wars tally with 
those observed by experimenters. Exaggerated destructive effects 
have been reported at 2000 yards or more, and they are most likely the 
effects of lateral pressure from tangential shots. 

Injury to the Epiphyseal Ends of Bones. — The results in all of the 
recent wars give convincing evidence of clean cut perforation with 
little or no fracture in nearly all cases of injury to the joint ends 
of bones. This is due to the fact that the bone in the epiphysis is 
soft and offers but little resistance, compared to that in the diaphysis. 
Unlike the lesion in the diaphysis the extent of injury is uninfluenced 
by velocity. Even close shots will show perforation, in the head of 
the tibia for instance, with little or no fragmentation. Perforations 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 57 

are not confined to jacketed bullets; they were sometimes seen with 
the use of the larger elongated lead bullets. The uniform perforation 
of the epiphyses of bones from the new bullet has contributed more 
than any of the characteristic effects of the new armament to make' 
the wars of the present more humane. 

Injuries to the Head. — A study of close shots in the living such as 
have been noted repeatedly from suicides shows the wounds of the cran- 
ial vault to be typical of the class known under the name of Explosive 
Effects. In such cases extensive fissures radiate toward each other 
from the points of entrance and exit; fracture of the base through the 
sphenoids and temporal bones are not uncommon, and instances are 
described in which the skull-cap and the skin covering it have been 
literally torn away. The observations that have been made among 
the dead and those who have lived to reach the field hospitals in recent 
wars show that at battle ranges even, the amount of comminution 
and Assuring of the bones of the skull is great. This was particularly 
so among those we saw at Santiago. 

EFFECTS OF THE POINTED BULLET OR BULLET "S" OF THE 

GERMANS 

A change is about to take place in the shape and weight of the bul- 
lets of the military rifles for all armies that deserves consideration at 
this time. This bullet is popular with military men because it has a 
flatter trajectory, and longer danger zone than any of the reduced 
caliber bullets tried so far. Such a bullet has recently been adopted 
by England, Germany, Turkey and the United States. The one 
adopted by this country has a pointed instead of an ogival head. It is 
1.08 inches in length; .3083 inch in diameter; weight 150 grains; the 
jacket is composed of cupro-nickel steel. The velocity of translation 
is 2700 f.s. at the muzzle, and the velocity of rotation 3240 turns per 
second as it issues from the weapon. The point blank range firing 
standing is 718.6 yards. The center of gravity of this bullet is dis- 
posed well toward its base. Experiments which we have made on 
cadavers demonstrate that the bullet is poorly balanced and that the 
slightest amount of resistance will cause it to turn on its short axis. 
The resistance in the hip-joint, the chest, and abdominal walls caused 
the bullet to turn in nearly every instance, as shown by keyholing in 
the head of barrels of sawdust immediately behind the target, and the 



58 



GUNSHOT WOUNDS 



resulting wounds were comparable to those inflicted by an expanding 
bullet. (See Figs. 34 and 35.) 

Doebbelin 1 reports probably the first case of a wound by the "S" 
bullet, which corresponds to our pointed bullet, in a soldier who was 
shot twice in the back, by a sentinel at 25 meters distance, as he was 
attempting to escape. There were two wounds of entrance about the 
size of a lead pencil. The first was located opposite the tenth rib 




Fig. 34. — Experimental shot in cadaver. Keyholing of pointed bullet in blotting paper behind 
target after going through hip-joint at a simulated range of 100 yards. 



near the right axillary line; the second was located 9 cm. to the right 
of the base of the coccyx. The wounds of exit were both large. The 
upper being about the size of a fifty-cent piece on the line of the right 
nipple, shattering the eighth rib, making a cavity at the point of frac- 
ture the size of a fist. The lung was uninjured. Wound of exit 
contained splinters of bone. The lower wound of exit was the size of 
a silver dollar containing bone splinters and a fragment of the bullet 
which was located 4 cm. below the crest of the right ilium near the 
anterior superior spine. After opening the abdomen the diaphragm 
was found lacerated from its attachment to the anterior wall of the 

1 Deutsche Mil. Aertztl. Ztschr., Berlin, 1906, XXXV, 625-628. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



59 



chest, and the bullet causing the upper wound had plowed through the 
dome of the liver making a channel 15 cm. long and 5 cm. in diameter. 
The intestines were not injured. A tampon was placed in the liver 
wound and the abdomen sewed up, leaving a drainage tube. The 
patient was discharged from hospital on the eighteenth day cured. 
Fig. 36 shows the effects of the U. S. Army pointed bullet on the 
femur at close range. 




Fig. 35. — Explosive effects in right thigh of a cadaver due to pointed bullet shot out of U. S 
magazine rifle at simulated range of 100 yards. Entrance wound round, size of bullet. Exit 
wound 6 inches long, by 3 inches wide; opening large enough to admit fist. Bullet hit femur in 
middle third causing extensive fragmentation and it then struck head of barrel behind the target, 
side on. A. M. School collection. 



Hunters 1 after large game have noticed the keyholing of the 
pointed bullet in soft and resistant parts alike, and the slashing 
effects are reported to be great. Col. Roosevelt in his African Game 

1 Stewart Edward White and Chas. Newton in "Arms and the Man," June 
1, 1911. 



60 



GUNSHOT WOUNDS 



Trails 1 states that the Winchester 405 and Springfield cal. .30 were 
the weapons, one of which he always carried in his hand, and he adds 
"for ordinary game I much preferred them to any other rifles." At 
280 and again at 180 yards, the full-jacketed sharp-pointed Springfield 
rifle bullet brought down two Eland bulls, each with one shot, as heavy 




Fig. 36. — Pvt. E. S., C. A. C, U. S. A., a prisoner, attempted escape from guard at Ft. Wayne, 
Mich., May 17, 1909. Shot with .30 cal. Springfield rifle using the service cartridge of 1906 ammuni- 
tion, pointed bullet. 

On entrance to hospital patient was in state of shock. Wound entrance 1 inch to right and 1 inch 
above anus size lead pencil. Wound exist at outer border of right thigh just below great trochanter 
3 inches by 3 inches in diameter and greatly lacerated, filled with broken bone. The whole hip 
presented a greatly contused aspect. Further examination revealed compound comminuted frac- 
ture of right femur just below great trochanter. An extensive area of loose bone was plainly 
palpable. 

Subsequent history of case marked by suppuration, secondary operation for necrosis, and 3 1/2 
inches shortening with complete use of leg. Exposure made in 1910. 

Reported by Major D. C. Howard, Med. Corps, U. S. Army. 

as a prize steer, the bullet making "a terrific rending compared with 
the heavier ordinary shaped bullet of the same composition." For 
heavy game like rhinos and buffaloes he personally preferred a double 
barreled Holland 500-450. An examination of some heads of hippos 
and rhinos in the new National Museum at Washington shows remark- 
able crashing effects of the soft-nose bullet of the latter rifle against 

1 African Game Trails by Theodore Roosevelt, pp. 141-142 and 190-191. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



61 



thick resistant bone. Col. Roosevelt 1 again informs us that at 350 
long paces he brought down a hyena "with its throat cut, the little 
sharp-pointed full-jacketed bullet makes a slashing wound." At 
360 yards while shooting against giraffe he states 
that "the sharp-pointed bullet penetrated well with- 
out splitting into fragments, causing a rending shock. " 
The same reports come to us from isolated cases 
of injury upon the natives by the new pointed bullet 
in the Philippines. The effects of the pointed bullet 
in the Turko-Balkan War of 1912-1913 have sus- 
tained the estimates of the experimenters as to its 
degree of deadliness. The body wounds in the 
two belligerent armies seldom lived to receive 
hospital care. The high ratio of wounds by shrapnel 
which in themselves cause an excessive mortality 
among body wounds have come in to mask the dead- 
liness of the pointed bullet, but the reports of all the 
observers are unanimous on the field mortality. 
Fig. 37.— Photo- Major P. C. Fauntleroy, M. C, U. S. Army, our 
graph showing Turkish attache with the armies in the field from Jan. 1 to 

cartridge and bullet .. . . . ,. 

used in Turko-Baikan March 15, reports the approximate total casualties 




War. 


in the Bulgarian 


Army as follows : 






Killed 


Wounded 


Died from wounds 


Officers 

Soldiers 


400 
23,000 


1,000 
55,000 


300 
10,000 



About 20 per cent, of all wounds were from shrapnel. 

If we add the number of officers and men killed and wounded, we 
find the ratio of killed to wounded to be 1 to 2 . 5. The very few 
abdominal wounds that lived to reach hospital care were prone to 
develop localized septic peritonitis with abscess. Penetrating chest 
wounds by the spitz-ball, as the pointed bullet is called over there, 
were prone to the development of complications like pneumo-hemo- 
thorax, pyothorax, etc. Of the wounds by the spitz-bullet that reached 
hospital care, the majority were not serious and recovery occurred in 

1 Op. cit., pp. 197-198 (2), 205. 



62 



GUNSHOT WOUNDS 



from four to six weeks. Much to the surprise of the observers the 
pointed bullet often lodged. This was attributed erroneously to 
defective ammunition. 

With simulated velocities at 800 to 1000 yards the bullet in our 
experiments already referred to showed great tendency to lodge upon 
striking against compact and cancellous bone tissue. The field sur- 
geons in the Turko-Balkan War also reported its lodgment most gen- 




Fig. 38. — Skiagram of fractured humerus with explosive effects by Turkish bullet at battle of 

Lule Burgas, 400 meter range. 

erally at 800 to 1000 meters, especially when resistant bone was hit, 
and they saw explosive effects at short ranges when resistant structures 
were traversed. 

It requires no prophet to predict that the war wounds of the 
future will be much more grave. Body wounds will be more uni- 
formly fatal; injury to bone will be more extensive and prone to sup- 
puration. The humane character of the reduced caliber bullet 
wounds so happily noted in recent wars will be less frequent. This 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 63 

will be especially true of wounds of the lungs and epiphyseal ends 
of bones. 

The European War has now been waging two full years and the 
fact of the foregoing, written in the previous edition of this book, is so 
true, that accusations of, and recrimininations of the use of dumdum 
bullets have already been made repeatedly. No one, who is acquainted 
with the mechanics of the pointed bullet believes that the nations at 
war have resorted to the use of bullets that are proscribed by the 
comity of nations. It is unfortunately too true that the pointed 
bullet under certain conditions has all the power to produce the ugly 
wounds that are caused by deforming bullets of the dumdum type. 

The Germans have been blamed for the adoption originally of the 
spitz bullet. They wisely made the selection because the pointed 
projectile offers less resistance to the air, it travels longer in a straight 
line than the ogival headed bullet, and this fact has materially added 
to its continuous danger space, so much so, that tacticians have 
favored it to the exclusion of other projectiles. 

In the same way it is unfair to accuse the English of using a double 
core in their bullet (p. 33, Chapter I) to add to the severity of wounds. 
The change in their ammunition was the result of experiments which 
they made in an endeavor to lengthen their bullet to give it more bear- 
ing surface in the barrel and thereby render it steady in flight. By 
lengthening the bullet with its lead core they added weight to the 
ammunition, which is very objectionable to tacticians in these days of 
rapid-fire guns. In order to overcome this objection they substituted 
aluminum for the lead tip of the core. 1 

It is doubtful if this bullet more readily undergoes deformation 
than bullets having single lead cores. The increased amount of frag- 
mentation can only be a shade in difference, and when we consider 
that the stability of the two bullets is equally faulty, we see no tan- 
gible reason for accusations, and recriminations. 

In spite of the fact that the pointed bullets are unsteady and prove 
to make irregular impact, from a number of causes, and thereby in- 
increase the severity of wounds, it is nevertheless true that a large 
percentage of wounded go back to the colors in an incredibly short 
space of time. Furthermore, we are told that the ratio of killed to 
wounded is variously stated to be as 1-5 and as small as 1-10. A 
recent report from Germany declares that 90 per cent, of the wounded 

1 Stargardt. K., and Kirschener: English Bullet Wounds; Some Remarks on the 
Action of the Regular Infantry Bullet, and the Dumdum Bullet. J. Roy. Army 
M. Corps, June, 1915, p. 601. 



64 



GUNSHOT WOUNDS 



are returned to the colors. No exact data on the subject will be 
obtainable until some time after the end of the war. 

The character of the wounds and the ratio of killed to wounded largely 
depend on the armament used and the kind of fighting. Battles in the 
open with a prepon- 
derating rate of mili- 
tary rifle fire at the 
usual battle ranges 
would give a maj ority 
of light wounds with 
a less number of killed 
to wounded; whereas 
trench fighting at 
close range with hand 
grenades, machine 
guns, explosive shells 
and shrapnel would 
add to the number of 
killed to wounded. 





Fig. 39. — Skiagram showing oblique fracture tibia by ricochet Turkish pointed bullet. Lodged 
bullet was removed and shows to left of skiagram. 

The following skiagrams and photographs from the Turko-Balkan 
war of 1912-13 were presented to the War College Library by Major 
P. C. Fauntleroy, M. C, U. S. A. (Figs. 38 to 47). 

STOPPING POWER OF PROJECTILES FROM RIFLES, PISTOLS 

AND REVOLVERS 

The stopping power of firearms is of vital importance on certain 
occasions. The sportsman after large vicious game feels more secure 
when he encounters an animal at close quarters if he is armed with a 
rifle that propels a missile with deadly effect. For personal encounters' 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



65 





Fig. 40. — Skiagram showing a partial 
butterfly fracture by Turkish bullet. Lodged 
bullet deformed. 



Fig. 41. — Skiagram showing a lodged unde- 
formed Turkish Spitz bullet under skin. 





Fig. 42. — Skiagram showing a Turkish rifle 
bullet lodged in left knee-joint. 
5 



Fig. 43. — Skiagram showing a lodged Spitz 
bullet butt-end to. 



66 



GUNSHOT WOUNDS 




Fig. 44. — Skiagram showing a lodged Turkish rifle bullet. 




Fig. 45. — Skiagram showing Turkish rifle bullet lodged in right lung. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 67 




Fig. 46. — Skiagram showing lodged ricochet Turkish bullet from battle of Tamrach. 




Frc 47. — One and two are photographs of nucleus and envelope of lodged missiles in Fig. 46. 



68 



GUNSHOT WOUNDS 



in self defense, it is useless to carry anything but an effective weapon. 
At war with savage tribes or a fanatical enemy, a military man seeks 
to arm his soldiers with a rifle that delivers projectiles with telling effect. 
A fanatic like a Moro wielding a bolo in each hand who advances with 
leaps and bounds and who never knows when he is hit until he is shot 
down must be hit with a projectile having a maximum amount of 
stopping power. Again, the military man has to reckon upon the 
stopping power of projectiles against cavalry and artillery horses in 
charge. 

The stopping power of the reduced caliber rifle bullet though less 
than that of its predecessors the .45-caliber Springfield, Martini- 
Henry, old Mauser, or Gras, is still considered sufficient for all the 
purposes of civilized warfare. At least it proved so in the Spanish- 
American, Boer, Russo-Japanese and the Turko-Balkan wars. Even 
the stoical Japanese soldier fell back as a rule when he was hit the first 
time. Five per cent, of the Japanese wounded were never admitted 
to hospital. They were treated on the line, but we are not told that 
they altogether ignored the fact of being wounded. We may assume 
that for all the purposes of war among civilized nations the present 
military rifle possesses sufficient stopping power. Major Charles 
Lynch, U. S. Army, our attache with the Japanese Army in his report 
to the War Department, questions the stopping power of the Japanese 
bullet. This bullet is one of the lightest used by any of the nations, 
being 6.50 millimeters in caliber, 11 1/2 grams in weight. He states 
that "a man hit with the Japanese bullet will come on when it has 
passed through his body anywhere, except at a vital point." The 
stopping power of this bullet is not questioned by other observers but 
we are convinced of the truth of Major Lynch' s statement when the 
weapon is used against a determined enemy or a savage tribe. 
Col. Stevenson states that the " medical officers who served in the 
Wizirestan Chitral Expeditions of 1895 where Lee-Metford rifles 
were first used in warfare, and Mr. H. C. Thompson who wrote the 
history of the latter campaign, believe that the English small-bore 
then in use could not be depended upon to stop a savage or determined 
man in a charge. "Many of the enemy in these two campaigns 
continued to advance and fight after the receipt of from one to six 
wounds by Lee-Metford bullets." These bullets were only effective 
upon striking vital parts or parts concerned in bodily activity. Our 
own officers have repeatedly reported in a similar way against the ef- 
fectiveness of the Krag-Jorgensen bullet in the Philippine Campaigns. 






CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 69 

Colonel Winter and Captain McAndrew, Medical Corps, U. S. A., 
have related the following incident to the author which bears upon the 
failure in stopping power of our service rifle: In 1907 a Moro charged 
the guard at Jolo, P. I. When he was within 100 yards, the entire 
guard opened fire on him. When he had reached within 5 yards of 
the firing party he stumbled and fell and while in the prone position 
a trumpeter killed him by shooting through the head with a . 45-caliber 
Colt's revolver. There were ten wounds in his body from the service 
rifle. Three of the wounds were located in the chest, one in the ab- 
domen and the remainder had taken effect in the extremities. There 
were no bones broken. ^ 

Sportsmen after large game in the Jungle prefer to arm themselves 
with the larger calibers. On account of the superior penetration and 
extended range of the jacketed bullets, the reduced calibers are only 
preferred in the open. 

Because the stopping power of our . 38-caliber Colt's revolver had 
failed us on numerous occasions in the Philippines and elsewhere the 
War Department constituted a Board in 1904 composed of Col. 
John T. Thompson, Ordnance Department and the writer, as the 
medical member, to conduct a series of tests with bullets of different 
size, weight and other characteristics, to determine upon a bullet that 
should have the stopping power and shock effect at short ranges, neces- 
sary for a pistol in the military service. To conduct these tests the 
Ordnance Department furnished the Board a number of pistols and 
revolvers with certain ammunitions as follows: 

It will be seen by the table, pages 72 and 73, that the calibers varied 
between .476 inch, the greatest, and .3012 the smallest, which cor- 
respond to the extremes in variation in military pistols so far as was 
known to the Board. 

Lead, jacketed and metal patch or soft-nose bullets were used. 
To produce dum-dum effects the points of some of the jacketed bullets 
were filed to expose the lead. 

The form of bullets included the truncated cone, the spherical seg- 
ment, blunt point, hole in point, cupped point, and one with a hole 
in point filled by a copper shell, primed and charged (explosive bullet.) 

The weights of bullets varied between 92 . 6 grains and 288 . 1 grains. 

The initial velocities varied between 700 f.s. and 1420 f.s. 

The lowest muzzle energy was 191 foot-pounds and the highest 
was 415 foot-pounds. The revolvers and pistols were selected for 
their value in ballistic elements and not for a test of their mechanism. 






70 



GUNSHOT WOUNDS 



Revolvers and pistols being short-range weapons, 75 yards were 
agreed upon as the extreme range, 37 1/2 yards as the medium range, 
and near the muzzle as close range. Simulated velocities were used 
for the first two ranges. 

The Board fired altogether into ten cadavers, sixteen beeves and 
two horses. The shock on cadavers was estimated by the amount of 




Fig. 48. — Antonio Caspi a prisoner on the Island of Samar, P. I. Attempted to escape Oct. 26, 
1905. He was shot four times at close range in a hand-to-hand encounter by a .38 cal. Colt's re- 
volver loaded with U. S. Army regulation ammunition. He was finally stunned by a blow on the 
forehead from the butt-end of a Springfield carbine. 1. Bullet entered chest near right nipple, 
passed upward, backward and outward, perforated lung and escaped through back passing through 
edge of right scapula. 2. Bullet entered chest near left nipple, passed upward, backward and in- 
ward, perforated lung and lodged in back in subcutaneous tissues. 3. Bullet entered chest near left 
shoulder, passed downward and backward, perforated lung and lodged in back. 4. Bullet entered 
palm of left hand and passed through subcutaneous tissues and escaped through wound on anterior 
surface of forearm. Treated at military hospital, Borongan, Samar. Turned over to civil author- 
ities cured, Nov. 23, 1905. Reported by L. P. Lewald, 1st Lieut. Medical Corps, U. S. Army. ■ 



disturbance which appeared in a limb when the body was suspended 
by the neck. 

We found that the amount of shock as measured by this method 
was always proportional to (1) the sectional area of the bullet, (2) 
to the resistance which the bullet encountered on impact, and (3) 
that it was proportional also to the amount of tissue destroyed. 
The diaphyses of the long bones showed the greatest amount of resist- 
ance, and consequently the greatest amount of destruction, and the 
two latter — viz., resistance and destruction of tissue, which are so 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 71 

intimately associated with shock effects — were . invariably greater 
when a larger caliber bullet was used. 

In attempting to define shock effects or stopping power in living 
animals we had to consider shots against — 

1. Vital parts. 

2. Non-vital parts. 

3. The anatomy necessary to locomotion or parts essential to 
activity. 

(a) As one might suppose, all shots against vital parts from what- 
ever arm showed immediate and complete stopping power. 

(b) For shots in non-vital parts like the lungs, liver, intestines, 
etc., exclusive of large vessels the shock or stopping power increased 
with the sactii3nM-^rjea-Qf_ihe missile and it was notably less with the 
smaller sectional area projectiles although they possessed far more 
energy. 

(c) The stopping power of bullets upon colliding against parts 
necessary to locomotion or parts essential to activity was considered 
positive when fracture of the long bones occurred. Measured by this 
standard all the bullets tried possessed sufficient stopping power when 
for instance the tibia or femur was fractured. The stopping power of 
the larger caliber projectiles was considered positive in gunshot 
wounds of the epiphyseal ends of bones entering into the formation 
of the ankle, knee, hip, shoulder and elbow, and doubtful when these 
structures were traversed by the small .3012 caliber jacketed bullet 
of the Luger pistol. 

In those cases where an effort was made to increase shock effects 
and destruction of tissue by the use of metal patch or marred jacketed 
bullets, these expedients failed in the soft parts and epiphyseal ends of 
bones, because the resistance in these tissues was not enough to dis- 
integrate the projectile, or in any way to increase its sectional area. 

As quick firing is an important element in close encounters, we made 
a number of tests to demonstrate what would be the stopping power 
by delivering the maximum energy of different projectiles in quick 
succession at close quarters, in bodily regions like the chest and 
abdomen away from the spine and large vessels. In this way we pro- 
posed to see how many shots it would require to cause an animal to 
drop to the ground. The animals selected were beeves about to un- 
dergo slaughter in the Chicago stock-yards. Each animal was tied to a 
post, and at the conclusion of each test, which occupied but a few sec- 
onds it was immediately killed in the usual way by the stock-yard 



72 



GUNSHOT WOUNDS 



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74 GUNSHOT WOUNDS 

force. For the purpose of the quick-firing experiments we employed 
the following calibers: \47.6, 45.5 and .45 from Colt's revolvers; the 
.38-cal. Colt's automatic and the .3012 Luger pistol which employed 
the steel-clad bullets. All of the bullets used in the experiments lodged 
in the body so that every particle of energy was delivered with each 
bullet. The animals invariably dropped to the ground when shot 
from three to five times with the larger caliber Colt's revolver bullets, 
and they failed in every instance to drop when as many as ten shots 
of the smaller jacketed bullets from the Colt's automatic and Luger 
pistol bullets had been delivered against the lungs or abdomen. This 
failure on the part of the automatic pistols of small caliber set at rest 
at once the claims of the makers to the effect that the superior energy 
and velocity of their weapons was a controlling factor in stopping 
power. The Board was of the opinion that a bullet which will have 
the shock effect and stopping power at short ranges necessary for a 
military pistol or revolver should have a caliber not less than .45. 
The tests showed that the .47.6-caliber lead bullet has the greatest 
stopping power. Its weight is 288.1 grains, muzzle velocity 729 f.s.; 
muzzle energy 340 foot-pounds. The .45-caliber lead bullet slightly 
blunt point was next in stopping power. It weighs 250 grains with 
a muzzle velocity of 720 f.s. and muzzle energy of 288 foot-pounds. 
A slightly blunt point has the advantage of making a bullet bite better 
in striking a hard bone at an angle, or in clipping the edge of a vessel. 
All things considered such a bullet is best suited for the military service 
VJ in close combat. The Board considered that cup-pointed bullets such 
as the "man stopper" might be issued to troops fighting savage tribes, 
and fanatics in the brush or jungle. This bullet showed great execu- 
tion on live animals. It weighs 218.5 grains. It has a muzzle velocity 
of 801 f.s. and a muzzle energy of 288 foot-pounds. The edge of the 
cup readily mushrooms upon striking cartilage and joint ends of bones, 
thereby adding to the sectional area and stopping power. 

None of the full-jacketed or metal-patch bullets (all of which were 
less than cal. . 45) showed the necessary shock effect or stopping power 
for a service weapon. They failed especially in the joint ends of bones 
and non- vital parts which comprise the larger part of the target area 
presented by the human or animal body. In the event that an auto- 
matic pistol should eventually be adopted by the government it was 
recommended that the caliber should not be less than . 45, and that the 
point of the jacket should be made very thin and that the lead core 
be made of softer lead than that of anv of the bullets tested. The 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



75 



object of this was to invite mushrooming. We were well aware that 
this recommendation would not be adopted because the comity of 
nations frowns upon any device which is calculated to increase the 
severity of wounds in war. The United States Government has 
recently adopted the .45 caliber Colt's automatic pistol which uses the 
steel-clad bullet without features to invite deformation. 




Fig. 49. — Fracture of femur by Colt's 
new service revolver .476 cal. at simulated 
velocity of 75 yards. Army Medical School 
collection. 



Fig. 50. — Perforation head humerus with 
slight fracture by Colt's new service revolver 
cal. .476 at range of 37 1/2 yards. Army 
Medical School collection. 



Shock effects depend upon the sectional area of a bullet and the 
amount of energy which it delivers at the point of impact. A full- 
jacketed bullet which makes a clean fracture in bone, and then leaves 
the body, takes the greater part of its energy in flight. When the bone 
is very resistant or the j acket is marred, the bullet may disintegrate. Its 
sectional area is then increased, and it leaves its energy in the body in 
proportion to the amount of metal which it deposits in the foyer of 
fracture. When it lodges entirely, it parts with all of its remaining 
energy. In comparing skiagrams showing fracture one can estimate 
wholly or in part the amount of the remaining energy or shock effects 



76 



GUNSHOT WOUNDS 



in a given case by the amount of metal which is deposited. By this 
standard one will see at a glance the striking difference which is nearly 
always shown between a bone lesion by a full-jacketed bullet, one that 
is but partially jacketed, and one that is unjacketed as in the case of 
a lead bullet. Full-jacketed projectiles leave but few metallic par- 
ticles about the area of fracture as a rule. A partially jacketed bullet, 
like a metal-patch, or a bullet with nose marred purposely or other- 
wise, will leave numerous fragments, some of them much darker 




Fig. 51. — Fracture of humerus by Colt's 
new service revolver .45 cal. Bullet with 
blunt point, close range. Army Medical 
School collection. 



Fig. 52. — Fracture of femur Colt's new 
service revolver .45 cal. carrying a bullet with 
hole in point close range. Army Medical 
School collection. 



than others. Those that are darker or black represent part of the 
lead core, while the fragments of lighter shade represent part of the 
envelope. The presence of dark fragments alone indicates the result 
of a lesion by an ordinary unjacketed lead bullet or a shrapnel ball, 
and more often the latter if the case is one from the very recent wars 
in which shrapnel balls are so frequently used. 

The following skiagrams exhibit bone lesions in cadavers when 
fired into with projectiles from pistols and revolvers (see Table No. 3). 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 77 




Fig. 53. — Man-stopper bullets from Colt's new service revolver cal. 455 lodged against tibia and 
femur without fracture. Remaining velocity at 75 yards. Army Medical School collection. 



78 



GUNSHOT WOUNDS 



The X-ray work was done by Professor A. Hewson and Doctor W. M. 
Sweet, of Philadelphia (Figs. 49 to 68). 

We are not acquainted with any bullet fired from a hand weapon 
that will stop a determined enemy when the projectile traverses soft 
parts alone. The requirements of such a bullet would need to have a 
sectional area like that of a 3-inch solid shot the recoil from which 
when used in hand weapons would be prohibitive. 

Finally the Board reached the conclusion that the only safeguard at 
close encounters is a well-directed rapid fire from nothing less than a 




Fig. 54. — Fracture of tibia from man-stopper bullet fired from Colt's revolver new service cal. 
.455, velocity 704 f.s. Bullet fragmented and lodged just under skin. Army Medical School 
collection. 



.45-caliber weapon. With this end in view soldiers should be drilled 
to fire at moving targets until they have attained proficiency as marks- 
men. 

The pointed bullet recently adopted for the military rifle by the 
United States, Germany, and England, will no doubt exhibit greater 
stopping power than its predecessors which, as we have already shown, 
has hitherto failed entirely in encounters with savage tribes. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



79 




Fig. 55. — Fracture of femur by Colt's new service revolver, carrying man-stopper bullet, 
caliber .455 with simulated velocity at 37 1/2 yards. Note butterfly character of fracture. Army 
Medical School collection. 



80 



GUNSHOT WOUNDS 




Fig. 56. — Perforation by marred bullet from Colt's automatic pistol .38 cal. The jacket 
was not ruptured on impact. Range 5 yards velocity 1107 f.s. Army Medical School collec- 
tion. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



81 




Fig. 57. — Perforation neck femur by soft nose or metal patch bullet from Colt's automatic pistol 
.38 cal. at 5 yards. Army Medical School collection. 



82 



GUNSHOT WOUNDS 




Fig. 58. — Perforation head femur by the 9 mm. Luger pistol- jacketed bullet remaining velocity at 
37 1/2 yards. Army Medical School collection. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 83 




Fig. 59. Fig. 60. 

Fig. 59. — Fracture of tibia by Colt's automatic pistol .38 cal., full-jacketed bullet, remaining 
velocity at 37 1/2 yards. Metallic fragments are few in number and very small. Army Medical 
School collection. 

Fig. 60. — Fracture by Colt's automatic pistol .38 cal., full-jacketed bullet close range. 
Army Medical School collection. 



84 



GUNSHOT WOUNDS 




Fig. 61. — Fracture from soft nose bullet, Colt's automatic pistol .38 cal. at 5 yards. Army Med- 
ical School collection. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 85 




Fig. 62. — Fracture from soft nose bullet, Colt's automatic pistol .38 cal. at 5 yards. Army Med- 
ical School collection. 



86 



GUNSHOT WOUNDS 




Fig. 63. — Fracture of so-called man-stopper bullet from Colt's .455 caliber new service revolver 

at 5 yards. Army Medical School collection. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



87 




Fig. 64. — Butterfly fracture by Colt's automatic pistol bullet .38 cab, at close range, 
bullet was marred by filing the point of projectile. 



Jacket of 



88 



GUNSHOT WOUNDS 




Fig. 65. — Fracture from Colt's new service revolver unjacketed bullet .38 cal. at 25 yards. Army 

Medical School collection. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



89 




Fig. 66. — Fracture with butterfly arrangement of fragments from Colt's new service revolver, un- 
jacketed bullet, at 74 yards. Army Medical School collection. 



90 



GUNSHOT WOUNDS 




Fig. 67. — Fracture from Colt's new service revolver, unjacketed bullet, .38 cal. at 5 yards. 

Medical School collection. 



Army 



I 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



91 




Fig. 68. — Fracture by soft nose bullet, Colt's automatic pistol Cal. .38 at 5 yards 
ment of lead nucleus, fragmented. Army Medical School collection. 



Note lodge- 



92 GUNSHOT WOUNDS 

Explosive effects in gunshot wounds at proximal ranges by the high- 
power rifles were referred to in the beginning of this Chapter, p. 
37. They were noted by all experimenters upon cadavers and 
animals, and there is record of their appearance in war, especially 
in the Manchurian campaign. Generally speaking, these highly de- 
structive effects are commonly seen when using the older rifles like the 
.45-caliber Springfield and the Martini-Henry of the English Army 
up to 350 yards, and with the rifles of reduced caliber the character- 
istic effects have been noted still farther. 

The term " Explosive Effects" is in a measure confusing because it 
conveys the impression that the wound is the result of an explosion, 
or explosive bullet. The term is entirely descriptive and it owes its 
origin to the similarity in the appearance of a wound caused by an 
explosive ball per se, as compared to a bullet having sufficient velocity 
and energy to show a corresponding lesion, when a proper impact is 
made, as for instance, against resistant bone. As a rule the entrance 
wound presents no special features. In a few instances it may contain 
bony sand. When a resistant bone has been hit the area of fracture 
shows loss of substance, the bone will have been finely comminuted, 
the pulvarized bone will appear not only in the line of flight of the bul- 
let but in all directions, viz., at right angles to the channel and back- 
ward into the wound of entrance. Purification of the tissues will be 
noted along the parts adjacent to the channel made by the bullet and 
for some distance beyond. The exit wound is large and lacerated with 
the appearance of an explosion having occurred from within. Torn 
muscles, tendons, and at times lacerated nerves, mingled with pieces 
of bone, protrude from the injured parts. The channel from the 
wound of exit is funnel-shaped with the base of the funnel correspond- 
ing to the exit wound and the apex at the seat of fracture. 

Bony structures are not alone in showing these marked lesions with 
high velocities. Some observers have noted explosive effects up to 
500 yards with the reduced caliber bullet in "very vascular tissues, 
cavities filled with liquid, semi-liquid or viscous masses, such as the 
heart, skull, stomach, intestines, etc. Fig. 104 shows the effects 
of a proximal shot on the skull of a soldier who was endeavor- 
ing to escape from the guard at Fort Sheridan. The lesion is typical 
of explosive effects so-called and in our experience it does not differ 
from proximal shots on cadavers. For other evidences of explosive 
effects on the head see Figs. 101, 102 and 105. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 93 

We had never seen a wound caused by an explosive bullet, and in 
order to compare the lesion in such a wound with the explosive effects 
of bullets we fired into a horse's thigh while experimenting for the 
stopping power of bullets at Chicago. The bone lesion observed was 
not different in our experience from the lesion frequently described 
under the term explosive effects. 

All writers on the subject have sought to explain the so-called 
explosive effects, but it remained for Col. Stevenson in his book 
" Wounds in War," to give us a comprehensive description of the 
theoretical and true explanation of these interesting lesions. He 
takes up the subject under the following headings: 

1. The theory of compressed air. 

2. The theory of hydraulic pressure. 

3. The theory of rotation of the bullet. 

4. The theory of deformation of the bullet. 

5. The theory of heating of the bullet. 

At the onset we may state that none of the theories referred to 
comes up for serious consideration. They are merely mentioned to 
explain the confusion that once obtained in interpreting the mechanics 
of projectiles. 

1. Theory of Compressed Air. — This is among the oldest of the 
theories to explain explosive effects. The advocates of this theory 
believed that the projectile massed a cushion of compressed air on its 
head, and that on impact this compressed air again expanded, with 
more or less violence, not unlike the expansive force of an explosive, 
thereby causing the appearances of internal pressure which are noted 
in wounds showing explosive effects. There is no evidence of air 
having been forced into the tissues and we know also that air is ex- 
tremely mobile and that it can only be compressed when imprisoned 
under great pressure. 

2. Hydraulic Pressure. — This theory came into prominence because 
water when fired into, offers great resistance to the passage of a bullet. 
The act of firing into cans of water that are sealed or unsealed ex- 
hibits the effects of a powerful internal pressure. The hydraulic theory 
can only be employed to explain destructive effects in tissues where an 
organ like the stomach, or urinary bladder is filled with fluid at the 
moment of impact. In such a case the explosive effects simulate 
those seen in the case of a femur as far as lacerations and contusions 
are concerned. In reckoning upon the subject of explosive effects 
one must always bear in mind that explosive effects are proportional 



94 



GUNSHOT WOUNDS 



to (1) the velocity, (2) sectional area, (3) deformation and (4) to the 
resistance, on impact. Concerning the latter we may add that there 
are two things in the human body that offer a maximum of resistance, 
viz., compact bone and water. In order to exhibit its maximum resist- 
ance the water has to be in the form of a fluid or a semi-fluid mass 
contained in a cavity. 

The velocity of rotation as a cause of explosive effects needs but 
a passing notice. As we have already shown, the velocity of rotation 







Fig. 69. 



Fig. 70. 



Fig. 71. 



Fig. 72. 





Fig. 73. Fig. 74. 

Fig. 69. — Shows orifice of entrance in an empty tin at 10 ft. by the Krag-Jorgensen bullet. 

Fig. 70. — Shows orifice of exit in same vessel. 

Fig. 71. — Shows orifice of entrance in a tin filled with marbles. 

P'ig. 72. — Shows orifice of exit in the same vessel. Note the impression of marbles on sides 
of tin caused by lateral pressure. 

Fig. 73. — Orifice of entrance in a tin sealed and filled with water. 

Fig. 74. — Orifice of exit in the same vessel. 



of the reduced caliber bullet with ogival head makes 2400 turns per 
second at the muzzle, and the pointed bullet adopted by our army and 
that of Germany and England on account of added velocity makes 
3240 turns. The velocity of rotation does not diminish as rapidly as 
the velocity of translation, that is, it is better maintained even to 
the latter end of the projectory. The rotation of the small bullet is 
given to it by a shorter twist in the rifling, or one complete turn in 10 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 95 

inches. If a bullet makes a turn on its long axis in 10 inches of its 
flight when traversing the femur for instance — the latter being about 
1 inch in diameter — the amount of turning which it would do while 
fracturing the femur would about equal one-tenth of a turn, and it is 
not likely that this amount of rotation could in any way be responsible 
for the enormous effects noted in such cases. 

As to the theory of heating to explain explosive effects, our experi- 
ments quoted elsewhere have demonstrated conclusively that a pro- 
jectile does not become sufficiently heated by the act of firing to 
destroy microorganisms placed upon it. This being the case, the 
theory is, to say the least, not tenable. 

While we were experimenting with the new bullet some years ago 
we repeated many of the experiments of von Coler and others to show 
so-called explosive effects by firing into empty tins, tins filled with 
water, sealed and unsealed; tins filled with wet and dry sawdust, also 
tins filled with starch-paste and marbles. (See Figs. 69 to 74.) 

The True Cause of Explosive Effects. — If we bear in mind the 
factors necessary to produce explosive effects — namely, velocity, 
sectional area, deformation, and resistance on impact — we have to 
recall the fact that all these factors have abided with us, except the high 
velocities, since the early history of firearms. The latter appeared 
with the perfection of the military rifle. Of the factors mentioned, 
which relate to the projectile, velocity is the most potent and next in 
order come sectional area and deformation. The velocity of the old 
Springfield rifle bullet was 1300 f.s. and that of our present rifle bullet 
is 2700 f.s. The energy of the Springfield bullet was 1879 foot-pounds 
while the energy of the U. S. magazine rifle (now called the New Spring- 
field rifle) bullet is 2400 foot-pounds. Although the velocity has been 
doubled we find that the energy has not been increased correspond- 
ingly. This is due to the diminution of the sectional area and weight of 
the smaller bullet. The weight of the bullet was reduced in the change 
mentioned from 500 to 152 grains, while the velocity was doubled. 
The 152 grains jacketed bullet impressed with a remaining velocity 
of 1300 f.s., which was the maximum velocity of the Springfield's 
500-grain bullet, shows no explosive effects. If it travels at its maxi- 
mum speed 2700 f.s. or thereabouts, it causes enormous destructive 
effects so that we must attribute its power to destroy tissues to its 
superior velocity. When the two guns mentioned are shot side by side, 
at similar ranges, into parts offering the same resistance, it is found 
that the explosive effects of the two bullets are the same for the proxi- 



96 GUNSHOT WOUNDS 

mal ranges up to about 350 yards, and they continue to be equally 
severe with the smaller bullet up to 500 yards. On the skull of cadavers 
with brain and scalp in situ we have noted all the appearances of ex- 
plosive effects as far as 900 yards. 

If one will examine the foyer of fracture and the funnel-shaped 
channel leading to the wound of exit as a result of a gunshot injury 
by the heavier lead bullet at proximal ranges, he will find pieces of 
the disintegrated lead from the bullet, and bone particles, dispersed 
in all directions as already explained. It is most evident from a 
study of the force which caused these particles to penetrate the 
tissues, that they were made to act as secondary projectiles by 
some of the energy of the bullet, which was transferred to them at 
the moment of impact. In cavities containing fluid contents, the 
fluids are dispersed and part of the energy of the bullet is trans- 
ferred to particles of water or fluid masses, and they in turn are 
propelled from their original positions to act as secondary pro- 
jectiles. The true cause of explosive effects may be said then to be 
the transfer of energy from the bullet to particles of its own composi- 
tion when it disintegrates, as well as to spicule of bone, or particles 
of fluid, or soft tissues. The amount of destruction is measured by 
the degree of energy inherent in the bullet, and we should add that 
the latter depends upon the velocity which the projectile possesses 
at the time of impact. Sectional area and deformation of the pro- 
jectile favor destruction of tissue, but they are not essential, since small 
jacketed bullets that show no deformation upon colliding with resist- 
ant bone at close range exhibit explosive effects bearing close similar- 
ity to those instances when the envelopes and core of the bullet un- 
dergo fragmentation. 

WOUNDS BY PROJECTILES FROM THE ARTILLERY ARM 

These will include wounds by shells, shell-fragments and shrapnel. 

Shell Wounds. — Injuries from shells are more often inflicted by 
fragments of shells after bursting. They vary in accordance with the 
size and irregularity of the fragment. They are always lacerated and 
contused. Wounds of the limbs especially, bear great similarity to 
those seen in civil practice, from machinery or railroad accidents. 
Lodgment of missiles is often noted because the velocity of the pieces 
of an exploded shell is low. When a whole shell hits at a high rate 
of velocity, it carries everything before it. When striking the body 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 97 

of an individual, a large opening will be made corresponding to the 
size of the projectiles, and viscera adjoining the point of impact are 
dislodged and scattered. Longmore states that in the case of a limb 
which has been carried away by a shell or solid shot "the end which 
remains attached to the body presents a stump with a nearly level sur- 
face of darkly contused, ragged, but still connected tissues, deeply 
imbued with blood. The flesh presents an aspect of having been torn 
asunder, by a sudden irresistible force. The skin and muscles do 
not retract, as they would do, had they been divided by incision. 
Particles of bone will be found among the soft tissues on one side of 
the wound, but the portion of the shaft of the bone remaining in situ 
will probably be found unsplintered and without long projecting jags 
or points." When the velocity of the large projectile is low, the in- 
jury is quite similar, only it is attended with more laceration and a 
ragged condition of the skin. The surface of the wound is not so 
even. The bone of a limb exhibits larger spiculse with greater tendency 
to Assuring in the part of the bone remaining. There is more extra- 
vasated blood, and contusion of the soft parts is more apparent. In 
the case of a spent shell or shot there may or may not be external 
evidence of injury, but there will be evidence of extensive disorgani- 
zation in the way of contusion, laceration, crushing of soft parts, with 
or without bone lesion. 

In the Civil War out of 245,790 gunshot wounds 359 were reported 
due to solid shot, and 12, 520 to shell fragments. Since shells are now 
used to the exclusion of solid shot, wounds from the latter are no 
longer seen in modern wars. Shells are more especially used 
against material and wounds from this projectile or its fragments 
will not occur very frequently, except in siege operations and in naval 
combats. Shell wounds in the Spanish-American war aggregated 
7 1/2 per cent, of all wounds, but these were mostly from shrapnel 
balls. Although there are no definite figures yet available for this class 
of wounds in the South African War, it is safe to predict that the latter 
figure will hardly be exceeded. Makins reports that shell wounds from 
shell fragments formed but a small proportion of the injuries treated 
in hospitals in the latter war. His reference to this class of wounds 
is not hopeful. He states that "the features presented were those 
of lacerated wounds, while the more severe of the cases which survived 
only offered scope for operations of the mutilating class, so uncongenial 
to modern surgical instincts." Makins also states that in some cases 
the impact was made by the flat surface of a fragment from which there 

7 



V 



98 GUNSHOT WOUNDS 

was no visible sign of injury. In one case of this kind the blow was 
delivered upon the epigastrium of a soldier and it was followed by 
vomiting of a considerable quantity of blood. 

Wind Contusion. — The case just referred to by Makins would have 
been called a wind contusion by the older writers on gunshot wounds. 
When solid shot and shell were more often employed in battle, sur- 
geons often saw cases of extensive internal injury to the viscera, disor- 
ganization of soft parts, and even fracture of bone with no visible 
evidence of injury to the surface. Such cases were attributed to the 
rapid displacement of the air in the vicinity of the injured, and the 
subsequent shock from refilling of the vacuum thus caused. But in- 
telligent men like Longmore and Baron Larrey soon learned that the 
lesion in so-called wind contusion was the result of pressure of heavy 
projectiles having slow momentum, against a tough elastic skin. In 
such cases Longmore believes that the blow is delivered obliquely and 
that as the elastic skin yields, the more resistant structures beneath 
are crushed and disorganized. There is nothing in our knowledge in 
the way of air displacement that will cause lesions marked by the dis- 
organization mentioned except the sudden liberation of the gases of 
the high explosives, and in these cases there is always tearing of the 
skin with other traumata. 

The statistics of injuries by shells and shell fragments in the Man- 
churian campaign, like those in the Spanish- Amerian war, are not relia- 
ble for the reason that "in the field nearly all wounds classified as 
Shell Wounds were caused by Shrapnel" (Lynch). Follenfant 1 states 
that wounds by shells charged with chimose powder were very different 
to those made by Shrapnell. The envelope of these chimosed shells 
was reduced to small particles, like scales, or cubical in shape, with 
sharp sides and angles which were apt to tattoo the wounded like so 
many grains of salt. The mental shock caused by the explosion and 
the resulting wounds brought on nervous symptoms, especially in 
officers, like neurasthenia or traumatic hysteria. These nervous symp- 
toms were also attributed by some observers to poisoning from the 
gas of explosion, which was absorbed from the small fragments, lodged 
in the cellular tissues. 

For a complete description of the effects of large projectiles in 
modern war we have to turn to the labors of our naval confreres. 
Surgeon General Charles F. Stokes, U. S. Navy 2 , calls attention to the 

1 Archives de Medecine et de Pharmacie Militaires No. 48, 1906. By M. 
Follenfant, French Army. 

2 Proceedings of New York State Medical Society for 1912. 



CHAKACTERISTIC LESIONS CAUSED BY PROJECTILES 99 

probable casualties and deadly results in future wars between modern 
battleships. The new 14-inch guns on board have an effective range 
of 14 miles and they can fire with accuracy on moving targets at 7 to 9 
miles with amazing rapidity. Each of the guns fires a projectile weigh- 
ing 1400 pounds at a velocity of 2900 f.s. The powder charge of a 14- 
inch piece weighs 350-400 pounds and in addition it carries a bursting 
charge that invites extensive fragmentation of the projectile on impact. 
Both the propelling and bursting charges are largely composed of the 
modern high explosives which yield poisonous gases like CO, and NO2, 
as products of combustion. Indeed one of the chief menaces in naval 
warfare to-day will be poisoning from powder gases arising from the 
bursting shells of the enemy and the batteries on board each ship. 
As pointed out by General Stokes there will be two types of poisoning 
— "one resembling illuminating gas poisoning, the other irritative in 
its effects. Both may vary in degree. In the one group, in mild 
cases, we find dilatation of the pupil, impaired vision, a fall in blood 
pressure, a rapid heart action and possibly some mental confusion." 
Slighter degrees of poisoning will doubtless impair the effectiveness of 
the men, and larger dosage will cause them to succumb into unconscious- 
ness and death. The best account in our literature on the effects of 
modern naval armament in recent wars is found in the Japanese 
Government Report by Saneyoshi and Suzuki 1 on the casualties of 
the naval combats in the Chino- Japanese War in 1894-95. Aboard 
ship the character of wounds from shells and shell fragments hitting 
the vicinity of the men differs materially from that seen in battle 
on land. On board ship injuries arise from splinters of planks and 
furniture, pieces of iron, etc., which are mobilized by bursting shells, 
and act as secondary projectiles. A shell exploding a magazine 
causes many injuries by burning and the fumes of powder gases in 
confined places are very irritating to the mucosae. The rending 
effects of the sudden displacement of air by detonating explosions is 
mentioned as an additional agent in causing injury. 

The injuries on board ship are divided as follows: (1) contusions, 
(2) abrasions, (3) penetrating, (4) perforating, (5) lacerating, (6) 
mutilating, and (7) burn. 

(1) Contusions. — The proportion of simple contusions are relatively 
small because of the limited range, and on account of the irregularity 

1 The Surgical and Medical History of the Naval War between Japan and 
China, 1894-95, by Baron Saneyoshi and Doctor Suzuki, Japanese Navy. 



S4 



100 GUNSHOT WOUNDS 

of the surface of the projectiles, which invite direct injury to the skin 
with resulting abrasion, laceration, etc. 

(2) Abrasions are for the above reasons more frequently noted, 
and they are often incurred by fragments striking obliquely. 

(3) Penetrating Wounds. — These wounds are inflicted by missiles 
possessed with low velocity and they find lodgment in the majority of 
cases. The penetrating wound shows but one wound — that of 
entrance. 

(4) Perforating Wounds. — These wounds are marked by a wound 
of entrance and one of exit. They are usually caused by small pieces 
of shell about the size of a .38 caliber projectile and more or less regular 
in outline. The wound of entrance conforms to the shape of the pro- 
jectile with lacerated edges, showing contusion of the adjoining tissues. 
Except in cases where the skin is stretched over bone or tendon, 
the wound of entrance is smaller than the wound of exit. The wound 
of exit is larger at times when the fragment leaves the body with its 
largest diameter at right angles to its line of flight. As a rule the resist- 
ance of the tissues causes the fragment to turn, so that its largest 
diameter remains coincident with the direction in which it is moving, 
making a smaller exit wound thereby. 

(5) Lacerated Wounds. — These wounds are usually inflicted by 
a shell or a large fragment. They are marked by section of the body 
in two parts, the severance of the head, hand or leg from the body. 
Forms of injury are also noted where continuity of the body still 
persists, as after extensive laceration of the chest or abdomen. 

(6) Mutilated Wounds. — This term is used to describe the wound 
in cases where the body or anatomical part is mutilated beyond 
recognition of its human form. Those sustaining the mutilation of a 
limb survive but a short time as a rule; they usually succumb to shock 
rapidly. 

(7) Burn. — This is by far the most frequent injury seen in naval 
combat. It comes directly from the explosion of shells and the ignition 
of ammunition in the vicinity of the explosion, and it sometimes 
arises from steam, which is liberated from containers that are perfor- 
ated by projectiles. On the " Matsushima " a 30-cm. shell struck a 
gun-shield, and as it exploded it set fire to some ammunition near by. 
One hundred sailors were killed and wounded. Twenty-five had the 
body destroyed entirely; one suffered mutilation of all four members; 
four were entirely burned. Of the seventy wounded twenty-two 
succumbed to burns in from twenty-four hours to a period of six weeks. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 101 

In the more serious cases, the face was blackened, the hair singed, the 
head was covered with black-yellowish scabs, the eyes were closed, the 
nostrils were obstructed and the ears were tumefied, the mouth was 
opened with difficulty. 

Saneyoshi and Suzuki note that traumatic delirium is the most 
frequent complication of burn aboard ship and that of all injuries in 
naval combat burn is the most painful. 

Rupture of Membrana Tympani. — This complication is often 
noted as a result of reverberations from the firing of cannons and the 
explosion of shells. Rapid displacement of air in the vicinity of deto- 
nating ammunition is offered as an additional cause. 

Primary Hemorrhage. — This symptom is rarely seen in shell 
wounds for reasons already referred to. But two deaths were reported 
in the Chino-Japanese war, one from a shell injury of the larger vessels 
of the abdomen, and the other from a piece of shell which cut through 
the neck from side to side severing the trachea, esophagus, and right 
carotid. Secondary hemorrhage is practically absent, presumably 
on account of the use of modern methods in wound treatment. 

Shock is not so dependent upon the location or character of the 
wound as it is to the mental state of the individual at the time of injury. 
Saneyoshi and Suzuki cite cases of shock in wounds of the head, chest 
and abdomen, as well as in cases of mutilated injuries of the limbs; 
and again cases of men are cited who labored under great mental excite- 
ment when hit and who though fatally wounded, with perforation of 
the abdomen, mutilated limbs, etc., showed no symptoms of shock 
whatsoever up to the time of death. Per contra, persons were seen to 
go into a state of shock which seemed to bring on paralysis of the 
nervous system from proximity to a bursting shell alone. Burn was 
responsible for many of the cases of shock. 

Traumatic delirium as a symptom is noted in those wounded who 
were in proximity to the explosion of large shells. Burn, nerve ex- 
haustion from pain, and loss of sleep are mentioned as contributing 
causes of traumatic delirium. Out of a total of 629 injuries received 
from various causes in the above-named war 50 . 2 per cent, were due 
to shells and shell fragments as follows: 

Contusions 19 cases in 14 persons. 

Abraded wounds 47 cases in 30 persons. 

Gutter wounds 6 cases in 6 persons. 

Wounds attended with loss of soft 

tissues 4 cases in 4 persons. 



102 GUNSHOT WOUNDS 

Contused wounds 97 cases in 59 persons. 

Penetrating wounds 57 cases in 41 persons. 

Perforated wounds 33 cases in 30 persons. 

Lacerated and mutilated wounds occurred as follows: 

Hit by entire shell 10 cases. 

Hit by fragment shell 27 cases. 

Hit by iron pieces 5 cases. 

In the neighborhood of shell explosions, causative 

effects uncertain 8 cases. 

Uncertain whether hit by shell fragment or iron pieces 2 cases. 

By compression 1 case. 

Total 53 cases. 

For excellent colored plates showing wounds by shell fragments, 
burn and other lesions which occurred in the Japan and China War, 
1894-95, see the Surgical and Medical History of the Naval War by 
Baron Saneyoshi and S. Suzuki, Tokio. 

Dr. Matthiolius 1 also reports upon the gravity of modern naval 
war wounds from the battle of Chemulpo, the first engagement in the 
Russo-Japanese War. The Russian Cruiser "Varyag" was put out 
of commission in fifty minutes with a casualty list of 41 killed and 64 
wounded, being 18 per cent, of her effectiveness. On account of the 
large penetrating steel shells, men were completely mutilated, ampu- 
tations were immediately necessary in a number of cases. One of the 
sailors received 160 wounds from the explosion of one shell. In the 
same war Dr. Totsuka 2 in a total of 2321 casualties in naval engage- 
ments, from all causes, before Port Arthur from February 9, to October 
1, 1904, gives a mortality of 1022; 88 died from unknown causes, 556 
of the wounds were severe and 655 were classed as slightly wounded. 
The exact number of casualties which may be attributed to shells or 
their fragments is not given. He states that the shell wounds were 
generally multiple. In 36 wounded there were 62 wounds, not count- 
ing excoriations and slight wounds. Some wounds were the size of a 
pea, others large enough to mutilate a limb. The wounds consisted 
of abrasions, contusions, blind wounds, perforating wounds, the last 
of these being less often seen, owing to the low velocity of fragments 
Small wounds healed rapidly, but the large wounds all suppurated. 

ia Les blessures dans la guerre Russo-Japonaise. Dr. Matthiolius, Marine 
Imperiale allemande Le Caducee, p. 11, 1904." 

2 Report of the Wounded admitted to the Sasebo Naval Hospital by K. Totsuka, 
Surgeon General I. J. Navy, Sei-i-kwai Med. Jour., May 31, 1904. 



GUNSHOT WOUNDS 



Plate B 






w 

X'.'lll' 

HiW/ 



Cloud of 5moke rnoM 

BURSTING OHRAPNEL- 



Eubst of HighExplosive HEAD. 

IK/VSMENTS FLYING 
IN kU DIRECTIONS . 



Fig. 1. — Compound comminuted fracture 
of the elbow-joint, with great loss of sub- 
stance, the result of a high-explosive shell 
wound. 



Fig. 2. — Generally considered the best 
projectile against zeppelins; a high-explosive 
"universal" shell bursting, with fragments 
flying in all directions. 




Fig. 3. — High-explosive shell wound of right shoulder attended with much comminution of upper 
half of right humerus. Larger blood-vessels and nerves intact. 

From A. M. Fauntleroy, op. cit. 

Facing page 103. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 103 

But more recently still we have in the present European war striking 
examples of the mutilating effects of fragments from modern shell 
fire on the field of battle. (Plate B.) 

Pom-pom Shell. — Wounds from this projectile or its fragments 
do not differ from injuries inflicted by the larger shell. The shell 
is fired from the Maxim automatic gun at intervals of a few seconds. 
It was first used in the Boer War. Makins states that the effect was 
principally a moral one, due to continuous firing of the gun and the 
unpleasant noise which it made. The shell failed to explode at times 
and as it was sufficiently small, the whole projectile was known to 
perforate the body in a number of cases. 

Wounds by Projectiles from Case Shot, Canister and Shrapnel. — 
The former of these have been altogether superseded by the use of 
shrapnel. Since their projectiles are similar in caliber, shape and 
weight, and generally speaking in composition to the shrapnel bullet, 
and as the balls of all these projectiles are possessed with low velocity 
on impact, the wounds they inflict are very similar, and they corre- 
spond to the description of wounds by shrapnel balls. Again, shrapnel 
wounds differ in no respect from wounds produced by spherical balls 
from low- velocity weapons of other days. The canister and shrapnel 
balls have generally been spherical in shape and of an average of .50 
calibers in diameter. Whether they are liberated by the shock of 
impact or a time fuse the velocity is low, the tendency is for the missiles 
to lodge, the wounds are often multiple, and they nearly always sup- 
purate. There were but 1153 gunshot wounds from grape 1 and canis- 
ter reported in our Civil War of 1861-65 out of a total of 245,790 
wounds from all kinds of projectiles. Since the modern shrapnel 
forms about 80 per cent, of the artillery ammunition on the field of 
battle we will expect more casualties from this source in the future. 
In recent wars the proportion of shell and shrapnel wounds taken 
together is very much increased in number. In the Manchurian 
campaign Lynch 2 states that for the first Japanese Army the mili- 
tary rifle wounds were 84 per cent., shell 14 per cent., and bayonet 
0.9 per cent. This army was engaged in field operations alone. In 
the third army which had only siege operations at Port Arthur and but 

1 The grape shot of the Civil War was made of about 9 spherical iron balls 
held together by rings and cast-iron plates. They separated by the shock of dis- 
charge from the cannon. 

2 Reports of Military observers, etc., Part IV. Report by Major Charles 
Lynch, U. S. Army, 1907. 



104 



GUNSHOT WOUNDS 








f 




m ST 






Fig. 75. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



105 














Fig. 76. 

Figs. 75 and 76. — Shrapnel balls, pieces of casing and other missiles removed from wounded soldiers 

in the Russo-Japanese War. From the U. S. Army War College collection. 



106 



GUNSHOT WOUNDS 



one battle, Mukden, the rifle wounds were 59 per cent., cannon 19.63 
per cent., bayonet 0.59 per cent. The percentages for the three armies 
taken together is: rifle 76.42, cannon 15.78, bayonet 0.63. The 
remaining percentages figure among the miscellaneous and untraceable. 
In the field all wounds classified as shell wounds were practically due 
to shrapnel. 

There were but few cases of shrapnel wounds reported in the 
Spanish- American War. In the South African War, the Boers were 
poorly provided with artillery. They used shrapnel with little effect- 




Fig. 77. — From Turko-Balkan War 1912-13. Bulgarian artilleryman wounded by a bursting 

shrapnel at Lule Burgas. 



iveness owing to bad marksmanship. The shrapnel wounds noted 
were from leaden shrapnel bullets mostly from British shells. "The 
wounds possessed little special interest except from the fact that the 
bullets were often retained" (Makins). The same author saw one 
patient who had suffered six penetrating wounds from the bursting of 
one shrapnel. Although the body wounds from shrapnel balls are 
considered uniformly dangerous to life, Makins mentions one case of 
remarkable recovery as follows: "A Boer wounded at Graspan. 
Aperture of entry (shrapnel) opposite eighth left costal cartilage, 1 
inch external to nipple line. The opening was circular and surrounded 
by an area of ecchymosis 4 inches in diameter; exit 4J^ inches above 



CHARACTERISTIC LESION'S CAUSED BY PROJECTILES 



107 



and to the right of the umbilicus. Patient was at first in a Boer ambu- 
lance, and only seen by me on the ninth day. At that date he was 
dressed and walking with a gauze pad and bandage over the wounds. 
From the exit wound, which was 1 inch in diameter, protruded a piece 
of sloughing omentum, the margin of the wound being everted and 
raised over a circular indurated area. It was thought best to 
allow the sloughing omentum, which was very foul, to separate 
spontaneously, and then to return the stump. At the end of three 





Fig. 78— Turko-Balkan War 1912-13. 
Bulgarian wounded by Turkish shrapnel at 
Kirk-Kalisse Fauntleroy collection. 



Fig. 79.— Turko-Balkan War 1912-13. 
Bulgarian infantryman wounded near 
Adrianople. 



weeks, however, the slough had not only separated, but the stump had 
retracted, and only a small granulating surface was left, which healed 
spontaneously." 

From the Manchurian campaign, Lynch states that the shrapnel 
balls were prone to carry foreign material from the men's clothing 
into the wounds. From other sources we gather that shrapnel balls 
lodged in 66 per cent, of the cases. All wounds from this source sup- 
purated. Wounds of the chest were often complicated by hemo- 



108 GUNSHOT WOUNDS 

thorax, pneumothorax, and empyema — conditions which demanded 
prompt attention. Nearly all shrapnel shots of the abdomen died. 

Follenfant in the same campaign states that shrapnel wounds 
differed according to the part of the shrapnel that inflicted the 
injury. Some of the shrapnels held the explosive in the head of the 
case. The latter and the metallic segments within, were broken 
and followed the cone of dispersion with the balls. The wounds 
naturally varied with the character of the missile — whether it happened 
to be part of the casing or the balls contained therein. The special 
feature of the wounds was their constant infection, as a result no doubt 
of the nature of the lesion, and the more frequent introduction of 
shreds of clothing into the wound. In the Turko-Balkan War of 
1912-1913 the ratio of wounds by shrapnel has exceeded that of all 
preceding wars. Fauntleroy 1 our attache in the field, states that of 
25,000 wounded received in the hospitals at Sofia from the battle- 
fields of Adrianople, Kirk Kalisse and Lule Burgas and other engage- 
ments in the vicinity the shrapnel wounds averaged between 25 and 
35 per cent, of the whole; that 86 per cent, of wounds from all arms 
were infected, and that 90 per cent, of the mutilating operations found 
necessary were the result of infection. His observations of the surgical 
wards of hospitals in Constantinople lead him to the belief that the 
ratio of shrapnel wounds on the Turkish side will be about 33 per cent, 
of all wounds inflicted at the battles of Kirk Kalisse and Lule Burgas, 
and that 60 per cent, of all those inflicted at Tchaltalaja were by shrap- 
nel. Other observers 2 found the frequency of shrapnel wounds in the 
Constantinople hospitals as high as 80 per cent. (Figs. 77 to 79). 

The world war now raging in Europe has given striking examples of 
the character and extent of the lesions that are caused by the modern 
shrapnel. (Plate C.) 

WOUNDS FROM GRENADES, BOMBS AND MINES 

Hand Grenades. — All the observers in the Manchurian campaign 
make note of the frightful wounds inflicted by the hand grenade. 
Hand grenades were first used by the Japanese at the siege of Port 
Arthur, but later they were used on both sides during the remainder 
of the war. McPherson saw many wounds inflicted by this device 

1 Report to the A. G. O., February, 1913, by Major P. C. Fauntleroy, M. C, 
U. S. Army. 

2 Lucas-Championierre, J. M. Chirurgien du Croissant Rouge, etc. J. de 
Med. et de Chirurgie Pratique, No. 24, Dec. 25, 1912. 



GUNSHOT WOUNDS 



Plate C 




Fig. 1. — This illustrates a shrapnel wound of the right arm with considerable destruction 

of tissue and loss of substance. 




Fig. 2. — Shrapnel wound of face with multiple fracture of lower jaw and considerabh 

loss of substance. 

From A. M. Fauntleroy, op. cit. 



Facing page 108. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



109 



and they were difficult to treat satisfactorily. The wounds were 
multiple. The injuries were often caused by the shattering effects of 
pyroxylin gas. Parts were completely carried away or so damaged 
as to require amputation. Another class of wounds was caused by 
strips of the casing. These were deep, lacerated wounds, leaving ugly 
scars and causing much disfigurement when the face was injured. 
The wounds were at first of a deep yellow color, the wounded suffered 
great pain, which persisted long after the wound had commenced to 
heal. Fig. 80. 




Fig. 80. — Wound produced by explosion of hand grenade, Russo-Japanese War. (Lynch.) 



Some of the wounds caused by the explosion of the grenades are 
described as very small and numerous, due to the lodgment of metallic 
particles. In addition to the physical injuries mentioned the worst 
effects of the explosion were moral. Only the best seasoned troops 
stood the fire. 

Wounds from Bombs and Mines. — The wounds produced by 
bombs are similar to those arising from the high explosives already 
referred to. The injuries from terrestrial mines are also similar, with 
the addition of the lodgment of foreign bodies in the wounds, composed 
of gravel, dirt, and splinters of wood. The latter came from the boxes 
in which the explosive is buried beneath the surface. Such wounds 



110 GUNSHOT WOUNDS 

are prone to develop the virulent infections arising from the bacillus 
aerogenes capsulatus and the bacillus of tetanus. 

Wounds from Pistols and Revolvers. — Our remarks upon the 
subject of the stopping power of pistols and revolvers, and the illus- 
trations exhibited in another part of this chapter bear to a large extent 
upon the characteristic effects of the wounds produced by the above- 
named weapons. The calibers of these weapons usually vary between 
.22 and .47.6, the latter being used but seldom. The majority of the 
wounds come from .38 caliber bullets. 

Projectiles from pistols and revolvers having lower velocities than 
rifle projectiles are less apt to fracture bone and they more often lodge 
than the bullets of the high-power rifles. As a rule the length of the 
pistol or revolver projectiles is much shorter than the longer stable 
bullet of the reduced caliber rifles. The length of the latter is usually 
four diameters; and for the smaller bore rifles, like the .25.5 caliber of 
the Japanese Army, the length of the bullet is as much as five diameters. 
The ballistician is wont to increase the length of his bullet as he reduces 
its caliber, and he does this to insure the stability of the bullet in flight, 
to keep it point on. This adds to both range and penetration, and for 
a military projectile it is very advantageous. The wound which such 
a bullet inflicts is generally round, corresponding to the caliber of the 
bullet. The channel is clean cut as it were, with a minimum of con- 
tusion, laceration and hematoma. The bone lesion is not so severe ex- 
cept for the proximal ranges. The epiphyseal ends of bones as we have 
already stated are generally perforated, with very little if any shat- 
tering. The pistol and revolver bullets on the other hand are much 
shorter by comparison. The length of any of them seldom exceeds two 
diameters and some of them, like the .45.5 caliber man stopper; the 
.45 caliber lead bullet with blunt point, the .38 caliber jacketed bullet 
for the automatic Colt's are less than two diameters in length. The 
bullets from pistols and revolvers are thus rendered very unstable as 
a rule. The least resistance on impact causes them to tumble, and 
then to crash through the tissues end over end, inflicting, thereby 
uglier wounds, wounds exhibiting laceration, contusion, hematomata, 
and all the characteristics which favor the reduction of local resistance 
in the tissues. 

Blank Ammunition and Toy-pistol Wounds. — Gunshot wounds 
from toy-pistols are of special interest to American surgeons, because 
they figure extensively in American surgical literature in connection 
with the production of tetanus. The same character of wound has 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



111 



been noted by Bonnette, Schjerning and others abroad, with similar 
complications. As we will point out in the chapter on " Infection of 
Gunshot Wounds" the injuries from the toy-pistol and other blank 
ammunitions are usually delivered at close range. The impact of 
such a charge causes much laceration, contusion, hematomata — the 
very conditions that augment the tendency to the development of 
the virulent infections. It is for this reason that toy-pistol wounds 
and wounds from blank ammunition deserve special consideration. 
Toy-pistol wounds in this country are inflicted accidentally about the 




Fig. 81. — Radiogram showing lodged pellets from shot-gun wound. Compound commin- 
uted fracture fibula. Loose fragments removed. Later infection from bacillus aerogenes capsula- 
tus developed, necessitating amputation. Army Medical School collection. 

time of the anniversary of our National Independence, and abroad the 
blank ammunition wounds occur about the time of the army maneu- 
vers, in the sham battles which accompany these exercises. 

Wounds from Shot-guns. — The characteristic features of wounds 
inflicted by small shot from the class of weapons known as shot-guns 
differ materially with the distance from the gun at the time of dis- 
charge, the size of the shot, the amount of propellant, the manner of 
loading or the kind of cartridge. The cone of dispersion made by the 
shot is influenced naturally by all of the foregoing, viz., the distance, 
size and number of the shot, the amount of propellant, etc. Close- 
range shots are marked by total destruction of tissues, laceration, 



112 



GUNSHOT WOUNDS 



hematoma and fracture of bone with extensive comminution, and by 
perforation and lodgment of individual pellets (Figs. 81 to 84). 

Gunshot Wounds from Small Target and Flobert Rifles. — The bore 
of these weapons is generally .22 to .32 caliber. The projectiles 




Fig. 82. — Radiograph showing lodged shot in upper thigh. Wounded accidentally by shot- 
gun within distance of 4 ft. After the surgeons had removed all missiles in sight, over 90 pellets 
were revealed by X-ray. Army Medical School collection. 

may be round, or elongated, the latter being of two sizes, the long and 
short. The weight of the projectile of the .22 caliber is about 15 
grains, that of the latter about 60 grains. The velocity of the U. S. 
Army target rifle ammunition is 969 f.s. For a very interesting fatal 
case of gunshot injury of the head by the .22 caliber target rifle gener- 
ally used in this country see Chapter VI, page, 180. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



113 



Doepner 1 gives some very interesting cases of fatal injury from the 
projectile of the Flobert rifle (Fig. 85). Fig. A, p. 113, is a deformed 
Flobert rifle bullet which passed through the frontal bone of a girl 
nine years old, and perforated the brain with fatal results. Fig. C 




Fig. 83. — A radiograph taken in 1911 of James A. Stewart, Co. "I" 81st Ind. Vol. Inf., and "G" 
45th Veteran Reserve Corps, who was accidentally shot in the right hand by a hunter, Feb. 8, 
1857, the shot entering the wrist and palm of the hand. The fingers are strongly flexed, and there 
is considerable atrophy of the muscles. U. S. Soldiers, Home collection, Dr. A. B. Herrick, X- 
rayist. 

is a bullet that penetrated the left hip in a man sixty-eight years 
old. The accident was followed by fatal tetanus on the nineteenth 
day. Fig. D penetrated a rib and the entire lung, causing fatal 
outcome from pleuritis and pneumonia. The other illustrations 



1 Doepner. Die gerichtsaerztliche Bedeutung der Flobertwaffen. 
Sachverst. Ztg., Berlin, 1908, XIV., 349, ff. 

8 



Aerzt. 



114 



GUNSHOT WOUNDS 



show deformed bullets from experimental shots on cadavers and 
boards. 

Wounds by Air-gun Projectiles. — The projectiles of air-guns are 
about .22 calibers, round in shape, and composed of lead. The pro- 
pellant is compressed air. The energy of the bullet is sufficient to 




Fig. 84. — Radiogram in case of J. M. showing ununited fracture of humerus and lodged shot. 
Wounded June 25, 1860, by accidental discharge of shot-gun, distance 2 ft. Exposure made Oct. 
1901. X-ray Laboratory U. S. Soldiers Home. Dr. A. B. Herrick, X-rayist. 

penetrate the tissues and fatal wounds from air-guns figure in the 
literature. The bullet causes a more or less contused and lacerated 
wound. The knee, eye, and abdominal cavity have been penetrated 
by the projectile with disabling and fatal results. 



CHARACTERISTIC LESIONS CAUSED BY PROJECTILES 



115 




Fig. 85. — Photographs of Flobert rifle bullets magnified three and one-half times. 



X, 



CHAPTER III 

Symptoms of Gunshot Wounds 

The symptoms of gunshot wounds are (a) pain, (b) shock, (c) 
hemorrhage, and (d) thirst. The first and last of these symptoms, 
viz., pain and thirst, are always present. Lodgment of a projectile, 
powder-burn and multiple wounds when present are usually referred 
to as complications of a primary nature, and not as symptoms. 

(a) Pain. — The amount of pain after the receipt of a gunshot 
wound depends upon the situation of the wound, its gravity, and the 
amount of tissue involved in the traumatism. We have stated al- 
ready that the amount of tissue involved is proportional to the veloc- 
ity of the projectile, its sectional area, and the resistance which the 
tissue traversed offers on impact. Writers on military surgery have 
observed interesting cases of what is called referred sensation among 
the injured. Makins mentions the case of a man who was struck in 
the head who first felt pain in the great toe, and another who was 
struck in the abdomen felt pain in his foot only. A Civilian War Hos- 
pital 1 in the South African campaign mentions the case of a man who 
"fancied himself hit in the foot and at once sat down and proceeded 
to take off his boot with the intention of applying a first-aid dressing. 
His surprise was great when on taking off his sock he found no wound. 
He subsequently discovered that he was shot through the upper part 
of the thigh." 

In the heat and excitement of battle men have been hit by the 
missiles of the old armament without knowing for a time at least 
that they were injured, and what is true of the old armament is true 
of the new, even more so. At Santiago we repeatedly questioned men 
who came from the front during the battle on this point. Some said 
they felt a sudden rap followed by a feeling of burning; or a blow, as 
from a hammer, a stone, or a cane. Others likened the pain to the 
sting of an insect. Many of the men stated that they did not know 
when they were injured and they were ignorant of the presence of a 
wound until their attention was called to it by a comrade, or the sight 
of blood. Pain when present was more often felt at the wound of 

1 A Civilian War Hospital by the Professional Staff thereof, etc. London, 1901. 

116 



SYMPTOMS OF GUNSHOT WOUNDS 117 

exit. The wounded experienced a sense of stiffness about the part hit, 
which caused pain on motion and they preferred to remain quiet. 
Makins refers to an amusing instance of entire absence of initial pain 
in a man who was shot through the buttock, the bullet subsequently 
traversing the abdominal cavity. The patient was ignorant of having 
been wounded until on undressing he found blood on his trousers and 
exclaimed "why I have got this bloody dysentery." Nevertheless, 
the wound was so serious in its nature that he died as a result of it in 
thirty-six hours. 

The sensation of pain is apt to be blunted to the point of anes- 
thesia in wounds from solid shot, shell fragments, and the high-power 
rifle bullets at close range against resistant bone. In such cases the 
tissues are devitalized and there is a deadening of sensation in the 
injured part. In injuries of this magnitude there is always more or 
less shock, and the lack of appreciation of local pain may in some cases 
at least be due to the effects of constitutional shock. 

(b) Constitutional Shock. — Military surgeons dwell on the train 
of symptoms of a depressing kind which is called shock, and which 
seems to be specially marked in gunshot wounds. In cases showing 
extensive injury like the wounds involving comminution of large resis- 
tant bone so common in shots by the high-power rifle at proximal ranges, 
in penetrating wounds of the large cavities, and again in wounds from 
the artillery class of missiles like shell fragments, or in the case of a 
limb carried away by a solid shot, there is commonly present an 
immediate disturbance of the nervous system which exhibits decided 
bodily and mental depression, the amount and duration of which is as 
a rule not proportional to the gravity of the injury. The patient in 
most cases is seized with extreme pallor of the skin and mucous sur- 
faces; the surface of the body is cold and clammy; a state of tremor, 
notably of the limbs, supervenes; the pupils are dilated, the heart's 
action is irregular, the pulse is weak, thready, irregular, and imper- 
ceptible at the wrist in marked cases; the respiratory movements are 
irregular and shallow, usually accompanied by deep sighing respira- 
tion; the features show mental apathy or anxiety and distress; there is 
impairment of superficial sensibility, and nausea and vomiting are 
often present. In the stress of battle there is often a kind of shock 
attended with great excitement and much restlessness, in which the 
movements of the patient are difficult to control, the reverse of the 
bodily and mental depression already referred to. We knew a vigor- 
ous young officer in the Sioux campaign of 1876 who was shot in the 



118 . GUNSHOT WOUNDS 

head, wrist, groin, knee and twice through the body, who exhibited 
pallor and other symptoms of shock. When we first saw him he was 
carried by four men who held the four corners of a blanket on which 
he lay. He uttered piercing cries at the top of his voice, he labored 
under great excitement and talked incessantly. He was perfectly 
conscious, asked for water, and made an effort to give a message to 
be transmitted to his family, but he was soon seized with the wild 
agitation of a moment before and failed to finish the message. He 
continued in this restless state until death took place a half hour 
later. 

In other cases the mental tension of the wounded whose tempera- 
ment is at all times placid will apparently control or suppress a state 
of shock for an indefinite time after the injury. A captain of the 1st 
Cavalry in the Guasimus fight in the Santiago campaign was shot 
through the body by a Mauser bullet. The bullet made a complete 
perforation of the body from back to front involving the right lobe of 
the liver and fracturing two ribs. He was conscious at the time that 
he had been hit from the flow of blood on his clothing and a sensation 
as if he had been struck by a stone, but he was engaged in aligning 
his men and correcting some confusion in his troop incident to a sudden 
volley after an ambuscade, and he completed what he had set to do 
before he was shot, and then, without ever falling to the ground he 
proceeded to the dressing station, a distance of 75 yards, where 
he placed himself under the care of a surgeon, after which a 
certain amount of shock supervened. He eventually recovered with- 
out operation. 

The placidity of the Arab and resistance against shock is well told 
by Captain Eugenio de Sarlo in the recent Italo-Turkish war in North 
Africa. 1 An Arab was wounded by the explosion of a grenade. There 
was a large abdominal wound, the omentum and a large mass of intes- 
tines protruding through the wound, with perforation of the protruded 
intestines in various parts, and entire ablation of the right hand. The 
wounded was in good condition when the reporter commenced to per- 
form a laparotomy convinced at the same time that the operation would 
be of no avail. He sewed up a number of lateral tears and a circular rent 
in the intestines and left a drain after partially sewing up the abdominal 
wall; he then amputated by a circular flap in the lower third of 
the forearm. The Arab endured the various steps of the operations 

1 Le Caducee, Nov. 16, 1912, comments on the Report of Captain de Sarlo 
on the wounded at Derna by Ed. Laval. 



SYMPTOMS OF GUNSHOT WOUNDS 119 

without complaint, on the contrary, he thanked the operator for his 
services from time to time. Immediately after the operation he asked 
to be returned to his home where he was taken at once, and where he 
immediately sat down and commenced to eat some dates. No fur- 
ther mention is made of the case. 

Sir Thomas Longmore, referring to cases where the temperament 
can exercise the faculty of control over alarm and depression, cites 
the case of a " sergeant who had the left arm completely carried off 
near the shoulder by a cannon ball at Waterloo. In this condition 
he started off and rode upright all the way from the field of battle to 
Brussels, a distance of 15 miles. " On reaching the hospital he became 
utterly prostrate. 

A temperament the opposite of the one just mentioned, one that is 
easily alarmed, may be overcome with shock after receiving a slight 
wound. In such a case it is not easy to determine the symptoms of 
shock from those of fear and cowardice. 

The duration of shock is variable and difficult to foretell. Some 
patients in profound shock will recover in a comparatively short time, 
while others in moderate shock may remain prostrate for an indefinite 
period, depending most likely on individual peculiarities. 

(c) Hemorrhage. — Hemorrhage as a symptom of gunshot wounds 
may be divided into (1) external primary, (2) recurrent hemorrhage, 
and (3) internal primary hemorrhage. 

(1) External primary hemorrhage refers to hemorrhage that 
comes from injured vessels which are situated externally and which 
may be readily reached and ligated by the surgeon. Here we refer 
more especially to the vessels of the extremities and neck. Hemor- 
rhage coming from the former situations, such as the vessels of the 
arm, forearm, thigh and leg, exclusive of the exposed vessels about the 
ankle and wrist, was considered very frequent once upon a time 
judging from the liberal distribution of tourniquets in the pouches of 
members of the relief corps. As a matter of fact external primary 
hemorrhage, under the designation mentioned, may be said to be rare. 
The Surgical History of our Civil War shows that primary hemorrhage 
only came under the observation of the surgeons in 5 per cent, of all 
wounds and in 3 per cent, in the Crimean War. Of the 1400 wounded 
at Santiago in 1898, the large majority of them being from the re- 
duced caliber Mauser bullet, no death from external primary hem- 



120 GUNSHOT WOUNDS 

orrhage was recorded and no vessel was tied on the field to arrest 
this kind of hemorrhage. The experience of the English surgeons in 
the Boer War agrees with the observations of surgeons in former wars. 
Makins, 1 referring to his experience in the South African War, states 
that external hemorrhage from the vessels of the limbs or even of the 
neck proves responsible for a remarkably small proportion of the deaths 
on the field. This statement may be made with confidence since it is 
not only his own experience, but it coincides with what he was able to 
gather from the experience of many medical officers on duty with bearer 
companies. He states that only one case of rapid death due to bleed- 
ing from a limb artery was recounted to him. This was the case 
of a man who was wounded in the brachial artery and who succumbed 
in 20 minutes, during the time that he was being transported to the 
dressing station. Col. W. F. Stevenson of the R. A. M. C, who was 
in charge of the line of communication in South Africa, states that 
" severe external primary hemorrhage from small bore bullet wounds 
of the vessels of the limbs, except when these are injured in regions 
where they are superficial, is uncommon." 2 Reports of Follenfant 3 
on the Russian side in the Russo-Japanese War confirm the rarity of 
avoidable external primary hemorrhage on the field in the Manchurian 
campaign, and it may be stated as a paradox that nearly all observers 
in recent wars agree that blood-vessels are more often wounded with 
the use of the present armament than formerly, and yet external 
primary hemorrhage of an alarming kind, always rare in battle, is 
seen less often than ever before. The following explanation is given 
for this apparent contradiction: formerly when the large leaden 
bullet with a hemispherical head moving at a comparatively slow 
rate of speed collided with one of the larger vessels the latter was 
pushed aside and if it was cut across or otherwise injured, there was 
no great tendency to primary hemorrhage because of the irregularity 
of the wound in the vessel coats. The armored bullets of reduced 
caliber are more definite in the work which they accomplish; they 
cut the vessels like a knife because of their superior velocity, smaller 
caliber and more pointed, ogival heads. The mechanical effects of 
forcing the bullet through the tissues is done so rapidly owing to greater 
velocity that there is no time for the vessel to be pushed aside. When 
one of the large vessels is hit fairly the small caliber of the bullet 

1 Surgical Experiences in South Africa by George Henry Makins, F. R. C. S. 

2 Wounds in War by Col. W. F. Stevenson, R. A. M. C. Ed., 1910. 

3 Op. cit. 



SYMPTOMS OF GUNSHOT WOUNDS 121 

permits it to make two clean-cut perforations going in and out, leaving 
no lacerated edges. There is in such a wound, as far as the vessel is 
concerned, every opportunity for immediate fatal external primary 
hemorrhage. When the vessel is hit at a tangent a clean opening is 
cut on one side which again affords every chance for immediate hemor- 
rhage, and fatal consequences would doubtless ensue in either case 
except for the following reasons: the channel of the wound being 
small, the narrow track is readily obstructed by a change in the 
position of the apertures in the muscles, intermuscular septa, fascias, 
etc., which causes obstruction in the continuity of the channel, hence 
the rarity of external primary hemorrhage from modern rifle bullets. 
In such wounds there may be no external evidence of hemorrhage, or 
possibly but a momentary spurt of blood, which is arrested as soon 
as the muscles change their position. Wounds of this character result 
in different kinds of aneurysms, which are more common in gunshot 
wounds now than hitherto, and which will be discussed under wounds 
of blood-vessels in another chapter. 

(2) Recurrent hemorrhage may be external or internal. In this 
form of hemorrhage the temporary obstruction in the way of interven- 
ing layers of tissue or clot gives way and favors the recurrence of 
hemorrhage. Makins, in his extensive experience in the Boer War, 
noted the occurrence of hemorrhage in several cases in the lower ex- 
tremities on the second and third days, which he styles recurrent hem- 
orrhage and for which ligation of the popliteal or femoral artery became 
necessary 

(3) Internal Primary Hemorrhage. — We include in this classifica- 
tion hemorrhage that occurs from injury to blood-vessels in the large 
cavities, like the thorax, the upper and lower abdomens. The vessels 
in these localities have not the firm support of those in the limbs and 
injury to their coats by modern rifle bullets which make clean-cut 
perforations bleed freely as a rule. In such cases Makins 1 states that 
"the potential space offered by the peritoneal or pleural cavities favors 
the ready escape of blood from the wounded vessel, while the tendency 
of the blood effused into serous cavities to rapid coagulation is notably 
slight." The mortality from this source on the field of battle has al- 
ways been considered very high before and since the change in the 
armament. Surgeon J. A. Liddell, of the U. S. Army, quoted by Otis, 
was convinced that a large proportion of the killed in battle perished 
directly from loss of blood as a result of internal primary hemorrhage. 

1 Op. cit. 



122 GUNSHOT WOUNDS 

Stevenson, 1 writing on the effects of present-day rifle bullets, believes 
that "it is much nearer the true state of the case to say that the great 
majority of those who die before succor can reach them succumb from 
primary hemorrhage. Some of the observers place the number of 
deaths from this cause as high as 85 per cent. " The statement is not 
surprising to those who have been on the line and witnessed the death 
struggle of the wounded. Body wounds, when death is imminent, are 
always attended with extreme pallor, great thirst, fluttering pulse, 
lowering temperature, etc. These symptoms might well be ascribed 
to shock, but in the latter restoratives usually relieve the condition, 
while in body wounds in which internal hemorrhage is going on we 
find that restoratives avail nothing. The fatality on the field of battle 
to-day is greater than ever before. In the Civil War and the wars 
preceding it, the average of deaths to the number of wounded stood 
as 1 to 4 1/2. In the Manchurian campaign the proportion is as 1 to 
3 1/2. Doubtfess the greater fatality arising from internal hemorrhage 
after rifle wounds is one of the factors which adds to the battle mor- 
tality of the present. At the same time that military surgeons agree 
that the fruitful cause of death on the field comes as a result of primary 
hemorrhage, no accurate estimate of the percentage of deaths from this 
cause has ever been made for the reason that the surgeons are gener- 
ally too much occupied in rendering aid to the wounded to devote 
any time to the dead. 

(d) Thirst. — A drink of water is one of the first requests made by 
men wounded in battle. Thirst is always present and it is very much 
aggravated if the wounds are attended with hemorrhage. The fact 
that this symptom is more apparent in soldiers is doubtless due to 
circumstances which often precede engagements, such as (1) forced 
marches in summer with few opportunities to obtain water; (2) sol- 
diers are taught to abstain from drinking because of the ill effects that 
indiscriminate drinking of water has on the endurance of men on the 
march; (3) exertion and loss of body fluids, perspiration, loss of sleep 
which induce a feverish state; (4) the ration in the emergent condi- 
tions of active campaign is usually made up of salt-meat and hard 
bread. All of the foregoing, with the excitement and din of battle, 
combine to excite the nervous system, and to produce thirst in the 
soldiery. The experienced military surgeon is always on the alert 
for means to provide water for the wounded, and among the many 
things he can do to alleviate suffering this is one of the most merciful. 

1 Op. cit. 



CHAPTER IV 

(1) Infection of Gunshot Wounds; (2) Poisoned Wounds 

Infection of gunshot wounds has to do with the following: 
(a) Virulence of the infection. 
(6) Environment. 

(c) Infection of wounds by modern armament. 

(d) Source of infection. 

(e) Sectional area of the projectile. 

(/) Constitutional and local resistance. 

(a) Virulence of the Infection. — The subject of virulence of the 
microorganisms that infect gunshot wounds is largely a study of the 
bacteriology or bacterial flora of war wounds, and gunshot wounds in 
general. 

The role which the bacteriologist has played in the present European 
war has been of material assistance in guiding the surgeon to a proper 
management of war wounds. Until the present conflict no war of 
any magnitude had been fought on highly infected soils to give the 
present day bacteriologist the opportunity to study the varied bac- 
terial flora of war wounds. The tragic consequences of the infections 
by virulent microorganisms has brought forth rich data for the use of 
the bacteriologist and the surgeon as well. Fortunately for the clini- 
cian and humanity, the advances made in the treatment of wounds in 
the present war exceed any development that has been noted since 
Joseph Lister first inaugurated the problem of the antiseptic treatment 
of wounds. 

The bacteriology of gunshot wounds may be divided into aerobes 
and facultative anaerobes, which require, or remain indifferent to the 
presence of, oxygen, and strict anaerobes which refuse to grow in the 
presence of oxygen. 

Staphylococci, streptococci, B. pyocyaneus and the colon group 
belong to the first group. Tetanus bacillus, B. of malignant oedema, 
B. aerogenes capsulatus, and a comparatively unknown collection of 
microbes which play an indefinite role in the etiology of gas gangrene, 
belong to the second. 

Staphylococci and streptococci are the common cause in the pro- 
duction of pus, cellulitis, and septicaemia. In addition, their devitaliz- 

123 



124 GUNSHOT WOUNDS 

ing effect on the tissues, enhance the growth and multiplication of 
the anaerobes, which are saprophytic in habit, and grow by preference 
on dead tissue. 

The colon group, including the B. coli communis, B. paratyphosus 
and B. typhosus itself are generally present in the discharges of war 
wounds, although the part which they play, if any, in the pathological 
process is unknown. 

The foregoing organisms are of low virulency, in the open especially. 
But in civil practice one finds them with greater virulency where they 
happen to have been transferred from host to host. 

Anaerobes. — The virulency of the anaerobes has been responsible 
for some of the most tragic consequences in the present war. Their 
presence in wounds having suitable soil for their growth leads to 
dangerous conditions, and the chief aim of military surgeon nowadays 
is directed toward their effects and their elimination. 

The virulent anaerobes which chiefly concern the surgeon are: 
B. tetani, B. of malignant cedema, and B. aerogenes capsulatus. 

B. Tetani. — In the vegetative stage this is a slender rod, slightly 
motile, and 4 to 5 microns in length. It rapidly forms spores at the 
temperature of the body. These are round, thicker than the cell and 
usually occupy one of its poles, giving the rod the appearance of a 
small pin. Bacilli which are morphologically identical with the teta- 
nus bacillus have frequently been found in the discharges in wounds 
from this war, but examination has failed to identify them with 
pathological or clinical significance. 

The manner in which the bacillus conveys its poison in the system 
and the pathological effects produced are too well known to require any 
extended reference here. The toxin is carried to the nerve cells of 
the central nervous system by the peripheral nerves. It attaches 
itself to the nerve cells of the medulla and pons, and by preference 
to those of the anterior cornual cells connected with the motor nerve- 
supply of the wound area. If a smaller dose than is required to produce 
typical symptoms is absorbed, the effects will be noted by slight 
cramps and discomfort in the inoculated part. Infection may result 
from trivial wounds, but as a rule infection is noted in larger wounds 
having devitalized tissue, and especially hematoma. 

According to the laboratory observations of Dudgeon, Gardner, 
and Bawtree 1 the bacillus of tetanus was found in the wounds of 11 
patients. Nine had received the immunizing dose of tetanus anti- 

1 Lancet, June 12, 1915. 



INFECTION OF GUNSHOT WOUNDS 125 

toxin, in none of whom tetanus developed- Of the other two, both 
non-immunes, one developed tetanus. They found further that 
tetanus bacillus may survive as much as two months in a wound with- 
out exhibiting the clinical manifestations of tetanus, and that the 
bacilli may be found in wounds marked by all degrees of severity with- 
out the presence of tetanus. 

We are indebted to certain experimenters for our knowledge of the 
manner in which tetanus has become so intimately associated with 
the traumatism of a gunshot wound: 

Lwowitch, 1 Strick, 2 and Dorst 3 have shown conclusively that hema- 
tomata augment the susceptibility to infection. They injected teta- 
nus toxin into the hematomata produced in rabbits by destroying the 
femoral artery subcutaneously with needles. By graduating the dose 
so injected, it was found that, compared to the amount necessary to 
produce lethal effects in a clean incised wound, hematomata aug- 
mented the susceptibility one thousand fold. In regard to the sus- 
ceptibility conferred by hematomata and the lesion in gunshot wounds, 
Strick found that the latter conferred greater susceptibility, and that 
the onset of symptoms in animals shot with tetanus balls is twice as 
rapid, and death ensues earlier, due no doubt to the hematomata and 
the state of devitalized tissues in and around the channel of a gun- 
shot wound. In experiments which we conducted at a later date 4 we 
found that in those cases where shots were delivered against suscep- 
tible animals at contact or thereabouts, causing burning or scorching 
from the ignition of the black powder charge which had been previously 
contaminated with tetanus earth, the development of tetanus was 
almost invariable in a very few days, showing that coagulation necrosis 
incident to powder burn augments the tendency to the development 
of tetanus infection. 

Toy-pistol Tetanus. — In this country the frequent occurrence of 
tetanus in men and boys who amuse themselves in celebrating the an- 

1 Lwowitch (pupil of Kocher) : Unpublished work described by Tavel in Revue 
de Chirurgie, 1899, xix, pp. 701-702. 

2 Strick : Die Tetanusinf ection von Schusswunden und Hsematomen ausgehend 
bei Kaninchen, mit besonderer Beruecksichtigung der Serumprophylaxis und 
Therapie. Inaug. Dissertation (Berne) Cologne, 1899. 

3 Dorst: Over den invloed van het hsematoom op het optreden van infectie in de 
chirurgie. Ned. Tijdschrift voor Genees-Kunde, 1896, 2R., xxxii, 2afd., 503-523. 

4 Mutter Lecture. — Poisoned Wounds by the Implements of Warfare, delivered 
before the College of Physicians, Phila. Journal A. M. A., Apr. llth-18th, 1903 
by Colonel Louis A. LaGarde, M. C, U. S. A. 



-r, , __„ , c GUNSHOT WOUNDS 

niversary of our National Independence by the use of explosives in toy- 
pistols, fire crackers, torpedoes, etc., has called forth renewed attention 
to the source of this infection. The majority of the cases have arisen 
from wounds by the toy-pistol, a .22-caliber revolver carrying six blank 
cartridges, loaded with an average of six grains of black powder, held 
in place by a paste-board wad. A study of the cases shows, that they 
are grouped, as to time, about July fourth. Now that some of the 
state legislatures have prohibited the use of the toy-pistol, the yearly 
number of cases is not so large as formerly. The boards of health of 
New York City and Chicago in three years' time have recorded as 
many as 158 deaths, and as many as 400 deaths from tetanus have 
occurred for the whole of the United States in the course of one year. 
Health reports from a number of the cities show that 35 per cent, of 
the cases have come from toy-pistol wounds. 

The source of tetanus in wounds by blank ammunition was care- 
fully studied by a number of observers. The work was directed toward 
the bacteriology of the powder and wads by means of culture methods 
and inoculations into animals. The powder was examined for acci- 
dental contamination, and, because so many observers had ascribed 
the introduction of the poison to the wad, we undertook a careful 
investigation of the possible contamination from this source. Al- 
though we found that the process of manufacture of card-board and 
other materials for wadding undergoes no treatment that is calculated 
to destroy resistant bacteria, and that they are manufactured from 
dirty rags, old paper, wood pulp, wool, etc., with every opportunity 
for contamination, our examinations were altogether negative. 1 
Our own examinations, those of the Director of the Health Depart- 
ment of Boston and other cities, those of Wells 2 of Chicago and others 
aggregating 675 samples of powders and wads, go to show that the 
bacillus of Nicolaier was absent in every instance and that the source 
of infection could not be ascribed to the blank cartridges. 

In some experiments on animals we succeeded in communicating 
tetanus in 69.5 per cent, of the cases by methods as follows: The 
experiments were conducted with the . 22-caliber toy-pistol. An 
artificial tetanus earth was made by mixing 1 quart of sterile earth 
with one agar-agar culture, after the toxin had been destroyed by 

1 Mutter Lecture, by the author, op. cit. 

2 Wells, H. Gideon, M. D. : An experimental study of the origin of the epi- 
demic of tetanus following July 4, 1899. Philadelphia Medical Journal, No. 1377, 
1900. 



INFECTION" OF GUNSHOT WOUNDS 127 

heating at 65°C. for five minutes. The animals were shot in the 
fleshy part of the thigh, and we succeeded in inflicting tetanus by: 

1. Infecting the powder grains. \/ 

2. We transmitted it by firing wads infected with tetanus-earth, and 

3. By placing the infected earth on projectiles. 

4. By placing 1 gram of tetanus earth in the barrel of the pistol. 

5. By shooting a blank cartridge through a piece of gauze pre- 
viously contaminated with tetanus-earth, the gauze lying against the 
part shot into. 

6. By placing 1 gram of wet tetanus-earth on the skin of the animal 
at the point penetrated by the charge. 

7. By infecting smokeless powder with tetanus-earth 1 

The control animals shot into, without the use of tetanus-earth, 
gave negative results without exception. The fatality attending our 
experiments aggregated 69.5 per cent. It is fair to assume that this 
percentage would have been greater with a pure culture of tetanus. 
Artificial tetanus-earth was used to simulate the actual conditions 
under which tetanus infections usually occur. 

Bacillus of Malignant (Edema. — The bacillus of malignant oedema, 
also called vibrion septique (Pasteur) , is another of the fecal anaerobes 
that has interested bacteriologists and surgeons in the study of wounds 
in the present war. Pasteur isolated it from cultures obtained in 
wounds from lower animals which he had previously contaminated with 
garden earth. When inoculated under the skin of rabbits and guinea- 
pigs there results a widespread oedema with more or less gas produc- 
tion. Its pathogenesis is somewhat like that of B. aerogenes capsula- 
tus, except that the latter causes less exudation of serum but an 
abundant production of gas, resulting in a rapidly spreading emphy- 
sematous gangrene. 

The bacillus of malignant oedema is a rod about 3 to 3.5 microns 
long by 1 to 1.1 microns thick. It is usually found in pairs, joined 
end to end, but may occur as longer threads in cultures. It readily 
forms spores in cultures and in the tissues. The spores are oval or 
nearly round and unlike the tetanus bacillus, they are placed in the 
center of the rod, though they are occasionally found nearer the end. 

When it enters war wounds, under favorable conditions, copious 
serous exudation is thrown out in the muscles and subcutaneous tis- 
sues. Gangrene soon results from the mechanical pressure of the 
exuded fluid on the blood vessels, and by the local action of the bacilli. 
1 Mutter Lecture, by the author, op. cit. 



128 GUNSHOT WOUNDS 

Gas production is not well marked, and it may be absent in pure in- 
fection. The toxin which is thrown out from the bacilli of malignant 
oedema is absorbed into the circulation and rapidly proves fatal. 
Although it is possible to prepare an antitoxin the same way that 
tetanus antitoxin is prepared, it does not seem to have been used thera- 
peutically as yet. 

B. Aerogenes Capsulatus. — This bacillus consists of straight or 
slightly curved rods having rounded ends, ranging from 3 to 6 microns 
in length, but it may appear in longer chains or threads. As its name 
implies, the rods are surrounded by a transparent capsule when ob- 
tained either from animal bodies or culture media. It is a non-motile, 
spore bearing anaerobe which stains with the ordinary aniline dyes 
and by Gram. The organism was first described by Welch in 1891 
and subsequently by Welch and Nuttall. 1 In this country it is known 
as the Welch bacillus, and by foreign writers it is often referred to as 
the Welch-Nuttall bacillus or B. perfringens. The gas gangrene so 
frequently noted in the early part of this war is attributed to the effects 
of the gas bacillus by most of the writers on the subject. Of the fecal 
bacilli found in wounds, it is more frequently associated with tetanus 
bacillus than any other, and its presence, which is readily detected as 
compared to tetanus bacillus, is strong presumptive evidence of con- 
tamination with tetanus bacillus. The evidence of its presence has 
therefore been used to prompt the clinician in using timely dosage of 
tetanus antitoxin, with the happiest of results. 

In the tissues it produces a free exudation of serum with abundant 
gas formation. The resulting emphysema spreads rapidly along the 
planes of connective tissue, and permeates muscles. The effusion and 
gas mechanically obstruct the circulation, and gangrene rapidly 
follows. 

At the same time that B. aerogenes capsulatus is the chief agent in 
the causation of gas gangrene, many writers have suggested that other 
bacilli are concerned in bringing about this complication. Fleming, 
in the Lancet of September 18, 1915, advances the theory that 
staphylococcus albus, which is a constant attendant in wound infec- 
tion, aids the growth of aerogenes capsulatus and that it favors the 
incidence of gas gangrene. According to his findings also, there are 
other spore-bearing anaerobes besides B. aerogenes capsulatus and 
bacillus tetani present in the early phase of wounds. These or- 
ganisms do not seem to possess any pathological significance, but 
they are highly putrefactive and emit a bad, sickening odor. 

1 Welch and Nuttall: Bulletin Johns Hopkins Hospital, No. 24, 1892. 



INFECTION OF GUNSHOT WOUNDS 129 

Dudgeon, Gardner and Bawtree 1 state that the severe infections 
are found in lacerated and devitalized tissues by preference, and that 
these tissues are in turn invaded by the bacillus aerogenes capsulatus, 
streptococci, staphylococci and coliform bacilli. In a study of 100 
cases they found all the wounds but one infected with aerobic and 
anaerobic bacteria, and that was a case of the knee joint, from which the 
bacillus aerogenes capsulatus was isolated in pure culture, where it was 
behaving as a pyogenic bacterium. They remark further that deep 
wounds with considerable damage to the soft parts or bone, with pro- 
fuse and effusive discharge are most liable to harbor bacillus aerogenes 
capsulatus. This organism may be present in such wounds or wounds 
of less severity without exhibiting any of the manifestations of gas 
gangrene. They suggest that it is probably necessary that some con- 
dition be present for the bacillus of Welch to give rise to gas gangrene. 
The bacillus aerogenes capsulatus has been found to survive in wounds 
4 weeks from the date of infection without the presence of gas gangrene, 
and in view of this fact, they very pertinently suggest the value of 
strict sterilization in the redressing of wounds. 

Death seems to result from a soluble toxin which acts on the heart, 
and Hull 2 states that a feature of the cases is the clearness of mind 
which the patients maintain with an imperceptible pulse. 

The evidence on the bacteriology of infected gunshot wounds as it 
has been revealed by the painstaking observers in the present World 
War was well known before. It had been worked out piece-meal by 
Lwowitz, Strick, Dorst, LaGarde and others as already pointed out in 
this chapter. The labors of Fleming, Dudgeon, Gardner and Bawtree 
have simply called attention to the subject anew, in one beautiful 
panorama. 

(b) Environment. — In addition to the strong liability to infection 
on certain battle-grounds, the multiplication of bacilli in a wound 
is favored by the disturbances to which the wounded are subjected. 
In military practice enforced transport complicates the results of treat- 
ment materially. After great battles there is usually insufficient 
personnel; the wounded lie unattended for hours in varying conditions 
of weather. Gunshot injuries to bones and joints, which require 
absolute rest, are not always properly immobilized. Lengthy trans- 
port, under such conditions, in springless wagons, over bad roads, adds 
much to the possibility of sepsis. 

1 Op. cit. 

2 Alfred H. Hull, Major, R. A. M. C. Surgery in War, P. Blakiston's 
Son & Co., Philadelphia, Pa., 1916. 



130 GUNSHOT WOUNDS 

(c) Infection of Wounds by Modern Armament. — Infection in war 
wounds with present-day armament, broadly stated, varies in fre- 
quency and extent with the character of the missile which inflicts them. 
Shells and shell fragments cause wounds attended with infection in 
modern wars as much as they did formerly. Wounds from this 
source require the unremitting care of the surgeon to arrest or curtail 
the infection which is invariably present. Hand-grenades, bombs, 
and mines inflict lacerated and contused wounds which invariably 
suppurate when the wound is of any magnitude. The shrapnel balls 
cause wounds that suppurate as a rule. The ball is round, .50 calibers 
in diameter, composed of lead, weighing from 167 to 288 grains. The 
contusion, laceration and hematoma which it invariably inflicts in 
the wound channel adds specially to the chances of infection. Modern 
rifle-bullet wounds exhibit less tendency to suppuration. The pro- 
jectile from the reduced caliber rifle now carried by foot and mounted 
troops is about .25.6 to .30 calibers. It is made up of a core of lead 
encased in an envelope of hard steel, the whole bullet weighing from 
150 to 220 grains. This bullet has caused the majority of wounds in 
recent wars and we find that wounds inflicted by it are for the most 
part apt to be humane and that they are prone to heal with but little, 
and at times apparently no suppuration. Still if one takes pains to 
carefully examine the tissues under the scab covering the wound of 
exit especially, he will generally find pus in wounds that are healing 
aseptically in the opinion of many surgeons. The wound of exit is 
generally larger than the wound of entrance, more lacerated, and the 
seat of this traumatism being in a dirty skin affords all the necessary 
opportunities for infection. In the Santiago campaign infection of the 
wound of exit from the Spanish Mauser bullet was the rule. In 
ricochet shots of soft parts showing irregular impact, suppuration was 
very prone to occur. Rifle-ball wounds attended with fracture of the 
long bones showed tendency to suppuration in proportion to the 
amount of comminution, the size of skin wounds, and attendant 
lacerations. Such wounds suppurated in spite of the proper applica- 
tion of the first dressing. Doubtless they would have had more chance 
for the introduction of additional infection without protection from 
the clean dressing, yet if a virulent infection had entered such a wound 
with the projectile, the first-aid dressing could have remained of no 
avail to prevent the subsequent clinical history of such an infection, 
notwithstanding the oft-quoted saying of Prof, von Nussbaum that 
"the fate of the wounded rests in the hands of ihe one who applies 



INFECTION OF GUNSHOT WOUNDS 131 

the first dressing." When one considers that the rifle bullets which 
inflict wounds in modern wars are carried in dirty bandoliers and 
handled by dirty hands, that they are not sterilized by the act of firing, 
it should be the exception to. find a wound in which healing takes 
place by first intention. When it does, it is because the wound is 
simple, in soft parts, through tissues having a well-developed local 
resistance, and not because the projectile is in any way sterile. Of 
the 1400 wounded in the Santiago campaign none of the virulent 
infections were noted, extensive suppuration from the ordinary pus- 
producing microbes was not often seen, and it was always easily con- 
trolled The absence of severe infections has been very properly 
attributed to the wide use of the first-aid dressings carried by the 
soldiers and members of the relief corps on the line. The improper 
application of these dressings, as shown by the way in which they 
became loose and failed adequately to protect the wounds to which 
they were applied, when examined at the Base Hospital at Siboney, 
demonstrated conclusively that there were other factors which 
assisted in preventing suppuration. The battle was fought on the 
first of July in a tropical climate by an army that was embarked two 
weeks before at Tampa, Florida. Because of the overcrowded con- 
dition of the ships the Medical Department insisted on daily baths 
to the men. They were placed under the hose at certain hours, so 
that their skins were clean on landing. Khaki was the uniform, and 
the rainy season had set in, so that the air was washed of dust daily 
by afternoon showers. The foregoing and the small frontage of the 
Mauser bullet of the Spaniards, which carried but few shreds of 
clothing into the wounds, contributed largely no doubt to lower the 
percentage of severe infections. 

Antisepsis and the use of projectiles of the reduced caliber rifle 
have combined to bring about marked beneficence in the war wounds 
of modern times. In the Civil War the mortality among those who 
reached the hospitals was 14.3 per cent. From the same class of 
cases the mortality was 6 per cent, in the Spanish-American War, 
8 per cent, in the Boer War, and in the Russo-Japanese War it was 
5.8 per cent, on the Japanese side and 3.4 per cent, on the Russian 
side. The material reduction in mortality since Civil War days, as 
already stated, is doubtless the result of the proper use of antiseptics 
and the change in the armament. 

(d) Source of Infection. — A gunshot wound may become infected 
in various ways. Infection primarily on the projectile itself may be 



132 GUNSHOT WOUNDS 

carried into the wound, because, contrary to what has been taught 
by many, it has been amply shown that the act of firing does not con- 
vey enough heat to a bullet at any time to render it sterile. 1 Granting 
that a bullet is sterile at the time of firing, it can gather infection by 
ricochet, or by passing through intermediate substances and thereby 
infect a wound. Infection is nearly always carried into the wound 
with shreds of clothing, the amount of the latter usually being in pro- 
portion to the sectional area of the bullet. A bullet can gather in- 
fection from a dirty gun-barrel, and, lastly, the skin which is pierced 
or punched by the projectile invariably contains infected matter, which 
is carried in with the bullet. The foregoing is true of all projectiles 
fired from hand weapons, including the most perfect of the high- 
power military rifles for all ranges, at least from near the muzzle to 
500 yards, as we have actually demonstrated by experiments on the 
target range, and no doubt the same is true of the maximum ranges 
for all hand weapons. 

It is true that projectiles are sometimes found in original packages 
practically sterile and free from septic germs. This was especially 
true of lead bullets that were lubricated by dropping in hot boiling 
grease, but contamination is unavoidable in the ordinary act of hand- 
ling and loading, so that it is safe to say that all bullet wounds are in- 
fected whether they show any marked evidence of such infection in a 
clinical way or not. A gunshot wound is certainly never bacteriologi- 
cally clean. 

(e) Sectional Area of the Projectile. — In the earlier years of gun- 
making the projectiles used in hand weapons were of large caliber and 
since they were composed of soft lead the tendency for such bullets 
on impact against resistant structures was to still further increase 
their sectional area. The wounds that were thus caused possessed 
all the characteristics that favor the development of infection, viz., 
hematoma, contusion, laceration, etc. Later, the lead composing the 
bullets was hardened by an admixture of about 5 per cent, of antimony. 
But at about this time the improvements in gunnery added greater 
velocity and energy to the projectiles, so that the tendency to defor- 
mation when the bullet collided with resistant bone was still marked, 
and here again the wounds showed those characters that augment 

1 Can a Septic Bullet Infect a Gunshot Wound? New York Medical Journal, 
Vol. LVI, No. 17, Oct. 22, 1892. Septic Bullets and Septic Powders, New York 
Medical Record, Vol. XVII, No. 25, June 22, 1895, by Louis A. LaGarde, U. S. 

Army. 



INFECTION OF GUNSHOT WOUNDS 133 

the disposition to infection. The relation between the original sec- 
tional area of a bullet and infection have always been marked for the 
reasons mentioned, and it is a matter of common observation that it 
is very much increased when the projectile flattens or disintegrates 
against bone, enough to disperse fragments in various directions. In 
such a case the metallic fragments acting as secondary projectiles 
cause additional laceration of tissue, contusion and hematoma. 

In recent years the sectional area of rifle bullets has been very much 
reduced — from .45 calibers to .30 and even less — and the influence 
of lessening the sectional area has resulted in marked beneficence in 
the character of the wounds. Besides lessening the sectional area and 
also the weight of bullets, their hardness has been very much increased 
by enveloping the lead bullet in a mantle of hard steel. The tendency 
to deform on the part of these compound bullets when colliding 
against the bony framework is very much reduced. The wounds — 
except at proximal ranges against hard bone — show fewer of the 
characteristics which formerly added so much to the development of 
infection. Such a bullet produces less traumatism in soft tissues, it 
perforates the joint ends of bones and except when it is possessed with 
high velocity on impact against hard bone, it is apt to produce a wound 
having the nature of an incised wound, comparatively free from the 
lesions which lead to the development of infection as already pointed 
out. 

(f) Constitutional and Local Resistance. — The general resistance 
of soldiers in arduous campaign is apt to be lower than normal, and 
whatever depresses constitutional resistance in the way of privation 
and hardship is apt to induce susceptibility to the development of 
infection. Local resistance is largely determined by the mechanical 
effects of the projectiles causing the injury. Microscopic examina- 
tion of the soft tissues surrounding the channel made by the bullet 
shows laceration, hematomata, and contusion, conditions favoring 
coagulation necrosis. In addition, dispersion of extraneous matter 
will be found, driven laterally by the energy of the projectile into the 
tissues to a distance of 17 mm., varying with the velocity and sectional 
area of the bullet. 1 This extraneous matter is lodged everywhere 
amid tissues wholly or partially devitalized. In such a condition the 
development of infection will be in keeping with the amount of trau- 
matism and the virulency of the organisms which have found access 
to the injured part. 

1 The Mutter Lecture by the author, op. cit. 



134 GUNSHOT WOUNDS 

(2) POISONED WOUNDS 

This is a subject so nearly related to wound infection that it can 
very properly be treated in this chapter. Reference to poisoned 
wounds is frequent in the literature of wounds by firearms. 1 The 
practice of poisoning implements of warfare like the spear, sword, 
arrowheads, knives, javelins, etc., dates back to the days of the Greeks 
and Romans. A practice that is abhorred to-day and classed among 
the most cowardly deeds in the list of crimes seems to have been pretty 
generally adopted in ancient times. Poisoned arrows were used by 
the ancients against man and beast. The Celts in the hunt poisoned 
their arrowheads with a substance which was called toxic. After 
wounding a deer, for instance, the seat of injury was excised at once 
to prevent rapid decomposition. They also used hellebore and a 
substance called limeum which was known as deer poison. The 
Vandals who inhabited what is now North Germany used various 
poisons, aconite being the most deadly, and Claude Bernard states 
that the practice of poisoning missiles was employed in more recent 
times and in the Spanish Army as late as the reign of Philip, the 
third. Some of the poisons, like curare, were said to cause death 
when introduced through a wound and they remained innocuous when 
ingested per os. Of the vegetable poisons most commonly employed, 
mention is made of extract of hellebore, aconite, yew, limeum, ninum, 
helenium. The nature of the last three of these is unknown to us. In 
this regard we may state that if all that is written of the lethal char- 
acter of some of the poisons used is true, the ancients were past- 
masters in the practice of what is to us a lost art. 

Among animal poisons used in modern times to poison missiles 
and cutting weapons for the hunt and in warfare by savage tribes in 
Africa, the South Seas, India, and China, may be mentioned decom- 
posing viscera, and snake venom. Anthrax and curare are used by 
tribes in West Africa and the tropical water-ways of the Amazon 
respectively. The inhabitants of New Caledonia infect their arrow- 
heads by dipping them in crab holes, and the experiments of LeDantec 2 
showed that animals inoculated with the poison some months after 
the preparation of the arrowheads die of either tetanus or malignant 
edema, but more often the latter. 

1 The Mutter Lecture by the author, op. cifc. 

2 Origine tellurique du poison des fleches des naturels des Nouvelles Hebrides 
(Oceanie), Archives de Med. Nav. et Col., 1893. 



INFECTION OF GUNSHOT WOUNDS 135 

Our North American Indians poisoned arrowheads and bullets in 
a more varied but less deadly manner. The poisoning of the war 
implements was more often done during a period of self-torture and 
fasting by the young warriors during a war dance or a religious cere- 
mony. The Comanches are said to have used the juice of the Spanish 
bayonet. The Sipares used the menstrual blood of a woman, while 
the Apaches prepared their poison by grinding the heads of rattlesnakes 
with fragments of deer liver. The Mo qui Indians irritate a rattle- 
snake to the point of madness. At this time it inflicts stings in its 
own body and the high priest of the Order of Snakes dips the arrow 
points or bullets in the bloody fluid. The poison thus prepared is 
said to cause death in three days. 

Our own work with septic bullets and septic powders 1 has shown 
that microorganisms placed on projectiles or on powder grains are 
not destroyed by the act of firing. We fired bullets from different 
kinds of hand weapons which were previously contaminated with 
anthrax germs into susceptible animals at varying distances up to 
500 yards and the animals died of anthrax in the majority of the cases. 
We also experimented with vegetable poisons, viz., curare and ricin, 
the latter being the most deadly of the vegetable poisons, and our 
experiments confirmed what appears in the literature, viz., the possi- 
bility of conveying poisons of any kind to man or beast by shooting. 

Follenfant makes note of the frequency of malignant pustule 
among Russian soldiers seen in the hospitals in Mukden in the Russo~ 
Japanese War, which, in a negative way, is of interest on the subject 
of wound infection. Cases were carried to the hospitals daily in 
January, 1905. The infection was attributed to imperfect tanning 
of the sheepskins from which their overcoats had been manufactured, 
the animals having died of peste siberienne. No case of wound in- 
fection showing the septicemic form of anthrax was observed, and yet 
the spores of the organism were doubtless carried into the wounds by 
the projectiles. In connection with our experiments with anthrax 
balls on animals, already quoted, the observations of Follenfant are 
very interesting. The Manchurian campaign points in this regard 
to a fact already appreciated, namely, that man is not susceptible 
like some of the lower animals to the septicemic form of anthrax. 
His susceptibility is only skin deep, as it were, hence the malignant 
pustule. The latter no doubt arose from infection of abraded sur- 
faces on the skin of soldiers wearing the infected sheep-skin overcoats. 
1 Mutter Lecture by the author, op. cit. 



CHAPTER V 

General Treatment of Gunshot Wounds 

Arrest of Hemorrhage. — The opportunity to arrest alarming 
hemorrhage will depend upon the character of the hemorrhage — 
whether it be external or internal. In referring to the latter kind — ■ 
internal primary hemorrhage, page 121, Chapter III — we called atten- 
tion to the apparent increase in the cases of hemorrhage which occur 
in the body cavities like the thorax and abdomen as a result of the use 
of reduced-caliber bullets. The treatment of internal primary hemor- 
rhage is attended with great difficulty because it is usually accom- 
panied by pronounced shock. Where life is jeopardized, an attempt 
should be made, in localities which permit of surgical interference, to 
cut down and ligate the bleeding vessels at the same time that all 
measures for the relief of shock are under way. External primary 
hemorrhage, as we have already stated, is rare. It takes place from 
vessels that are exposed or readily reached. But the ligation of bleed- 
ing vessels on the field of battle and in the emergent conditions which 
often obtain in peace is most difficult. Hemorrhage of a dangerous 
character rarely takes place in the presence of trained attendants and 
surgeons, when all the necessary facilities for operation are at hand. 
Until a favorable opportunity for interference has arrived, first-aid 
resources should be employed, and among these may be mentioned 
elevation of the injured part, extreme flexion, digital compression and 
antiseptic tampons. When the foregoing are not sufficient it is neces- 
sary to employ constriction, especially in gunshot wounds of the ex- 
tremities. The dangers of such a method in the hands of laymen are 
very much minimized if the precaution is taken of rendering the 
limb practically bloodless by gravitation before constriction is made. 
Constriction may be accomplished with an elastic bandage, a Spanish 
windlass, a pair of suspenders, or large handkerchief. The hospital 
corps pouches in the United States Army are provided with a strap 
of webbing holding a hard pad with a buckle attachment, to stay 
hemorrhage by constriction, while the orderly pouches which form 
part of the equipment for use of medical officers contain an elastic 
bandage 2 yards long and 2 inches wide. The constriction should be 
made rapidly, after the limb has been elevated, with sufficient firm- 

136 



TREATMENT OF GUNSHOT WOUNDS 137 

ness to control the flow of blood in the arteries and veins at the point 
of constriction. When pressure has been effectually applied as de- 
scribed it should not be maintained longer than three or four hours, to 
avoid danger from gangrene or paralysis. Such cases should remain 
under the watchful care of surgeons who are in possession of necessary 
hemostatic agents and equipment for ligation. 

Treatment of Shock. — There are some cardinal facts connected 
with shock which should be borne in mind: 

(1) One wounded, in a state of shock, should always be carefully 
guarded by trained assistants when reaction sets in. During shock 
the weak condition of the heart often starts hemorrhage from injured 
vessels that bleed freely as soon as the blood pressure is re-established 
and the heart commences to regain its normal volume. 

(2) When in a state of shock from severe injury the temperature 
falls to about 96.8° F., the prognosis is grave and the patient usually 
dies. 

(3) All the wounded who fail to recover their temperature in about 
four hours, or in whom reaction is not in proportion to the depression, 
should be considered as seriously injured and unfit to undergo operation. 
"The thermometer is an unfailing indication as to when operative 
interference may be permissible" (M. Retard). 

(4) Operations beyond ligation of vessels to arrest hemorrhage 
should be avoided during the state of shock, and transport, unless 
imperative, should be delayed. 

The relief of shock is directed toward measures calculated to 
restore the blood pressure. The possibility of secondary hemor- 
rhage should be remembered and the aim of the surgeon should be 
toward a gradual reaction. The first indication toward this end is 
the placing of the patient in the recumbent posture with his head on a 
level with the body, and restoration of the body temperature by the 
use of heat applied externally in the way of warm woolen blankets, 
hot- water bags, bottles, etc., with due care to prevent burns of the 
surface. Brandy or whiskey, diluted with hot water, should be 
gradually administered. An enema of 2 or 3 pints of normal salt 
solution is highly recommended by many surgeons. Transfusion 
of saline solutions in profound shock is often resorted to with marked 
results, supplemented by oxygen inhalations. Of the drugs in use, 
strychnia is one of the most popular, injected hypodermically. The 
Japanese in the Russo-Japanese War are said to have resorted to liquor 
camphorse as follows: camphor 1 part, ether 4 1/2 parts, and olive 



138 GUNSHOT WOUNDS 

oil 4 parts. This was used subcutaneously with marked benefit. It 
was the favorite remedy on the firing line. 1 In this country injections 
of adrenalin with normal salt solution are extensively employed. 
Four or 5 minims of adrenalin are dissolved at the time it is to be used 
in 500 c.c. of sterile salt solution to be injected in the cellular tissue 
of the flanks, buttocks or behind the breasts. 

The subject of the prevention and treatment of shock is not com- 
plete at this time without reference to the teachings of Crile who be- 
lieves that shock is a condition of exhaustion and low blood-pressure. 
He believes further that it may result from pain, hemorrhage, sepsis, 
worry and fear. He has demonstrated that painful stimuli can reach 
the brain, even in a state of general anaesthesia, which cause exhaustion 
of the brain cells. He has demonstrated histological lesions in the 
brain cells and in the cells of the liver and suprarenal capsules as well. 
Exhaustion of the brain cells deranges the vaso-motor mechanism with 
resulting changes in blood-pressure. In his preventive measures 
against the occurrence of shock, he seeks to prevent painful stimuli 
from reaching the brain by the use of regional anaesthesia. With the 
local anaesthetic he uses measures to maintain the blood-pressure, such 
as the transfusion of normal salt solution. To prevent the exudation 
of the fluid so injected into the connective tissue, he adds a small 
quantity of adrenalin to the solution. 

Crile opposes stimulation by the use of drugs, such as strychnia, 
alcohol, caffein, etc., on the ground that these only serve the purpose of 
further stimulating the already exhausted brain cells. 

He recommends control of pain by the administration of effective 
doses of morphia; local anaesthesia and nerve blocking should be em- 
ployed before extensive operations. Hemorrhage should be arrested 
and the blood-pressure maintained by the methods already mentioned. 

First Field Dressing. — The prophylaxis of infection in military 
practice has received a great deal of attention in recent years. The 
relief corps and the rank and file of all armies are drilled in time of 
peace in the methods of rendering first aid to the wounded, a great 
deal of which is devoted to the manner of preventing the introduc- 
tion of sepsis into open wounds. Men under instruction are cautioned 
not to touch the wound with their fingers or to allow anything to come 
into contact with it except a clean dressing. Every soldier in the U. S. 
Army carries attached to his cartridge belt a first-aid package enclosed 

1 Russo-Japanese War. Medical and Surgical Reports of Lt.-Col. W. G. 
McPherson, R.A.M.C. 



TREATMENT OF GUNSHOT WOUNDS 139 

in a hermetically sealed metal case. The contents are made up of 
two bundles of absorbent sublimated (1 to 1000) gauze 4 by 84 inches 
long, two compresses of absorbent sublimated (1 to 1000) gauze, each 
composed of 1/2 square yard so folded as to make a compress 3 1/2 by 
7 inches, two large safety pins wrapped in wax paper. The two com- 
presses and the safety pins are wrapped together in tough paper in 
which are enclosed printed directions for use of the dressing. All the 
contents are sterilized in a metallic case 4 1/2 by 2 1/2 by 1 1/4 inches. 
The words "First-aid Packet, U. S. Army," are stamped on the metal 
case. Aside from the value of having these first-aid packets ready at 
all times on the line, the medical transportation is spared a great deal 
from the burden of carrying sufficient dressing material to meet all the 
emergencies likely to arise at the front, and much labor is saved at the 
dressing station when the slight wounds have been properly dressed on 
the line. 

Iodine has recently been adopted for field use in our army as follows : 
Iodine is put up in hermetically sealed glass tubes, each tube containing 
1 gram of iodine and 1.5 grams of potassium iodide. Ten of these 
tubes are put up in a cardboard carton. Each hospital corps man 
carries one carton in his pouch, also a 4-ounce bottle. 

By putting the contents of two tubes in the bottle and filling the 
latter to its shoulder with water or alcohol one is enabled to make a 
2-per cent, solution, which is the strength recommended for first-aid 
use. The sealed tubes enter in the equipment of the field hospitals, 
ambulance companies and reserve medical supply depots. This 
method of carrying the iodine has the double advantage of a prepara- 
tion ready for use as a watery solution or a tincture. Alcohol could 
not be carried in quantities by hospital corps men on the field, hence 
the advisability of having a mixture easily soluble in water and which 
can be employed with alcohol when this is available. 

The greatest advantage of such a simple method of sterilizing the 
skin about the wound over the one that prevails in fixed hospitals, of 
scrubbing and washing with antiseptic solutions, lies in the fact that 
water in bulk of suitable quality is seldom found in active campaign. 

The iodine tincture or solution is painted over the wound and 
adjacent skin, being careful not to allow the preparation to collect in 
recesses of the wound when they are present. The iodine when allowed 
to collect in pockets is very irritating and its presence is a detriment. 
The wound is next dressed with the first-aid dressing previously 
described. In large lacerated wounds the contents of several of the 



140 GUNSHOT WOUNDS 

first-aid packets may be used ; or in the case of shell wounds, we carry 
in the United States Army a field dressing as follows: (1) a compress 
composed of 1 square yard of absorbent sublimated (1-^1000) gauze 
folded to make a pad 6 by 9 inches; (2) one bandage 3 inches wide by 
5 yards long of closely woven absorbent gauze (1-1000) rolled and 
wrapped in parchment or waxed paper, and (3) two No. 3 safety pins 
wrapped in waxed paper. The whole dressing is wrapped in tough 
paper with proper directions for use printed thereon. Short bandages 
are sewed to the compresses for the purpose of temporarily fixing the 
latter on the wound, after which they are firmly bound to the parts 
by the roller bandage. 

The field dressings of all armies are about the same, since they 
are intended to subserve the same purpose. The dressings are absor- 
bent and protective in design. An abundance of absorbent dressing 
is of special value to the military surgeon in field practice. By 
covering the wound completely with plenty of absorbent dressing, 
and in cases of deep lacerated wounds if the dressing is loosely packed 
in the wound, drainage will be maintained until a favorable oppor- 
tunity for redressing. In the case of large wounds when the time for 
redressing is indefinite, as often occurs in the emergent conditions of 
active campaign, cotton batting should be used over the absorbent 
dressing to protect the wound from outside contamination. With 
such a dressing it is possible to carry the wounded over several days 
until a field hospital has been reached, when all facilities are at hand 
for antiseptic and operative work. 

Immobilization. — Fixation of wounded parts plays a great role in 
gunshot wounds as a prophylactic against infection. When enforced 
transport is necessary, as so often happens in military practice, it 
adds much to the comfort of the patient in keeping down pain; it 
tends to prevent the recurrence of hemorrhage, and it favors early 
healing. 

When soft parts alone are wounded we immobilize by means of 
slings, a firmly fitting bandage, or splints to keep the wounded part 
at rest. In the case of wound of the chest or abdomen we apply a 
firm bandage about the body to check respiratory movements. 

Immobilization is also of special value in gunshot fractures. 
As soon as the first dressing has been applied fixation of the fragments 
is accomplished by woven wire splints, which are carried in the pouches 
of the relief corps men, also by extemporized methods such as immobiliz- 
ing the fractured arm or forearm to the chest by bandaging the member 



TREATMENT OF GUNSHOT WOUNDS 141 

to the body. In fracture of the lower extremity in military practice, 
in the absence of anything better, we improvise splints from folded 
blankets, gun scabbards, bayonets or rifles. 

Immobilization in all bone lesions, whether there is distinct solu- 
tion of continuity or not, should invariably be practised, and espe- 
cially so after lesion from the armored bullets. These hard pro- 
jectiles, when hitting the joint ends of the long bones, and also the 
diaphyses, in the mid ranges, have a tendency to perforate or gutter 
a bone without causing complete fracture. Transport and handling 
of a limb so injured without immobilization endangers the occur- 
rence of fracture and other traumatisms, which augment the danger 
to infection. Such an injury should be treated by permanent fixa- 
tion at once and it should not be handled unnecessarily. Many of 
these lesions, especially in the diaphyses, consist of perforation with 
subperiosteal fissures extending in the long axis of the bone and when 
the overlying support gives way from jolting, jarring or undue hand- 
ling, fracture takes place. This fact was referred to in our report 
to the Surgeon-General in 1893, when we tested a German silver 30- 
caliber jacketed bullet in cadavers under the orders of the War 
Department. 1 

In the living the case of Major T. J. W., 10th U. S. Cavalry, 
wounded at Santiago, is most applicable. He was wounded at 6 p. m., 
July 1, while in the standing posture looking through his field glasses. 
He felt a sharp blow on the left thigh which whirled him around. 
In endeavoring to pick up a pipe-stem which had fallen from his hand 
he fell to the ground and called for assistance to place him over the 
crest of the hill out of the line of fire. Wound of entrance by a 
Mauser bullet was found located at lower angle Scarpa's triangle 
and the wound of exit just below the rim of the pelvis on a line drawn 
from the center of the rim to the greater trochanter. The ball pierced 
the trousers pocket and a pocketbook therein and emerged from the 
skin, lodging in the trousers near the point of exit, where it was 
recovered. The passage of the ball through the thigh was from 
within and below, upward. A surgeon dressed the wound temporarily 
at once and applied splints from above hip at loin to ankle outside, 
and an inside splint from crotch to ankle. Fracture was diagnosed. 
After about one hour he was carried on an improvised stretcher to a 
dressing station about 3/4 mile to the rear. No redressing was 
done here and splint was not disturbed. The same night he was 

1 Annual Report, S. G. O., 1893. 



142 



GUNSHOT WOUNDS 



transported on a stretcher 4 miles to the field hospital where about 
1 a. m., July 2, the wound was dressed and leg again examined and 
fracture diagnosed by a second surgeon. The splints were reapplied 
and left on for two days more. A third examination was made when 
thigh was pronounced not fractured and the splints were removed. 
July 10 splints were reapplied and the patient was transported 7 




Fig. 86. — Case of Major T. J. W. 10th Cavalry, showing grooving of the trochanter major. Army- 
Medical School collection. 



miles over a rough road to the Reserve Divisional Hospital at Siboney. 
We were in command of the Division Hospital at Siboney and in charge 
of the evacuation of wounded. July 11, the day after arriving from 
the front, we had Major W. and a great many wounded loaded on the 
hospital ship Relief. His thigh was then in splints, the same as those 
applied on the day before in the field. The celebrated surgeon 



TREATMENT OF GUNSHOT WOUNDS 143 

Nicholas Senn of Chicago, then Lt.-Col. of Volunteers and consulting 
surgeon with the army in the field, examined this officer while he was 
in the Division Hospital at the front and he gave it as his opinion 
that there was no fracture. Two radiographic plates were made on 
the hospital ship Relief by Doctor Wm. M. Gray. Fig. 86 is made 
from the skiagram of one of the plates. It shows no fracture, but part 
of the greater trochanter gives evidence of guttering in the line of 
flight of the projectile from below upward. 

July 26 patient was transferred from the hospital ship Relief to 
the New York Hospital. On admission the limb had no splints. 
A fluoroscopic examination showed an oblique fracture through base 
of neck and part of greater trochanter with abundant callus and much 
displacement. The limb was found to be flexed and shortened 2 1/2 
inches. Wound exit was closed, wound entrance was suppurating 
slightly. No crepitus, no false motion, considerable tenderness and 
swelling about knee-joint. September 15 discharged from New York 
Hospital, with good motion of limb, shortening 1/2 inch. Took to 
crutches September 6, could bear some weight on injured leg. Major 
W. made a good recovery later and became a General Officer. The 
complete fracture took place after Doctor Gray's radiographic plate 
was taken on the Relief. 

The injury to the bone was made by a Mauser bullet which had 
lost some of its remaining velocity because it was lodged in the clothing 
as stated. It perforated the cancellous tissue of the greater trochanter 
which, like the epiphyseal ends of bones, exhibits perforation rather 
than fracture, especially with lower velocities. The mistake made 
was in taking off the splints before his admission to the New York 
Hospital. We know so much more about the effects of reduced- 
caliber bullets now that such a mistake is not likely to occur here- 
after. 

The measures calculated to prevent infection in the early treat- 
ment of gunshot wounds may be summed up as follows: 

1. The first dressing should be sterile, applied over a surface that 
has been painted with iodine. 

2. No attempt should be made to disinfect the wound proper on 
the battle field. 

3. Probing for bullets or the use of even a sterile finger in a wound 
is absolutely prohibited. 

4. The severely wounded, and gunshot fractures should not be 
transported unnecessarily. 



144 GUNSHOT WOUNDS 

5. Immobilization when indicated should be practised at once, 
and in bone lesion with or without fracture it should be maintained 
until firm bony union has occurred. 

Administration of Food and Stimulants. — The value of proper food 
and stimulants to the wounded can only be appreciated by those who 
have witnessed their effects on men who have been wounded in battle 
which, as frequently occurs, has been preceded by fatiguing forced 
marches, loss of sleep, and lack of food. As often happens the 
wounded have lost blood, and they have suffered pain and many 
discomforts in transport. Under these trying conditions men are in 
a low state of nutrition and vital power. Their resistance to microbic 
influences is much impaired and they are specially downcast in spirits. 
At such a time nothing is more indicated than food of a nourishing 
and stimulating kind. At Siboney after the battle of Santiago, we 
had a staff of helpers whose office was to supply the injured with 
beef-tea, hot gruel, chocolate, tea and coffee. We had captured a 
wine cellar on landing, which served the wounded with good burgundy, 
claret and sherry when required. 

In our Army, field, evacuation and base hospitals are provided with 
hospital stores for the sick in the way of beef-tea, brandy, chocolate, 
condensed milk, malted milk, rolled oats, soups, green and black tea, 
and whiskey. The dressing stations are supplied similarly. The 
effect of these necessary and kindly attentions on the wounded is 
magical. They become conscious of the presence of substantial help 
about them. Their hopes are raised and their despondency is replaced 
by good cheer. 

Inattention to the details of early feeding after great battles is one 
of the fruitful causes of death. Surgeons in the field should make 
special efforts to provide themselves with the articles mentioned 
when the battle is impending; the good results thereafter will be in 
keeping with the preparations made in advance. The allowance on 
the supply table should be no guide, it should be multiplied many 
times if opportunity offers. 

Treatment of Septic Wounds. — Evidences of sepsis in war wounds 
usually appear first at the field hospitals, and, under certain adverse 
conditions when the wounded cannot be reached to administer surgi- 
cal care it may be noted nearer the front, at collecting stations or dress- 
ing stations. At the earliest opportunity the first field dressing should 
be removed, under an anaesthetic if necessary. The redressing should 
be preceded by a thorough examination, and the measures of relief 



TREATMENT OF GUNSHOT WOUNDS 145 

to be instituted will be guided to a great extent by the X-ray findings, 
if this is available, as well as by the local and general symptoms. At 
this time the measures of treatment will include redressing, proper use 
of antiseptics and drainage; and, possibly the removal of foreign 
bodies, the removal of loose fragments of bone, excisions and amputa- 
tions, laparotomies, administration of food and stimulants, ligation of 
arteries for aneurysm, primary, secondary and recurrent hemorrhage. 
At the time of redressing suppuration will be present to a greater or 
less degree in all of the wounds. Suppuration will be found especially 
in the deep lacerated wounds from shell fragments, shrapnel, and 
rifle or machine gun bullets at close range. 

Simple gunshot wounds by armored bullets require little or no addi- 
tional treatment after the first dressing; they heal under a crust, and 
yet, if one takes pains to investigate, he will find slight suppuration of 
a superficial kind in every case, especially at the wound of exit, which 
soon disappears with rest and redressings after washing and painting 
the wound and surrounding skin with tincture of iodine. 

More serious wounds with the presence of infection require careful 
attention. The patient is placed on a table. The clothes are removed 
from the vicinity of the wound and a clean towel is placed beneath 
the injured part. The first field dressing is next cut away. The sur- 
geon and his assistants should now take the precaution of wearing 
gloves. In active campaign the rush of work leaves no time to wash 
and sterilize the hands with the scrupulous care that is so necessary 
to clean surgery, and for that reason, gloves save time, since one's 
gloved hands can be immersed in strong antiseptic solutions and 
thereby sterilized in a very short time. If at the redressing the 
surgeon finds a foul wound, a wet dressing is often used, and for this 
purpose sterile gauze wrung out of a weak antiseptic solution answers 
very well. Deep wounds will require plenty of counter openings and 
the free use of drainage tubes. Since all gunshot wounds that admit of 
immobilization should be fixed, a splint of some kind should be applied 
so that free access to the wound can be obtained at all times. 

Antiseptics. — For use in the form of lotions or for irrigation, the 
following antiseptics may be used : 2 1/2 per cent, carbolic acid, lysol 
one drachm to the pint, mercuric bichloride 1-4000, and peroxide of 
hydrogen in various dilutions. 

Tr. of iodine, 2 per cent., is a useful application for superficial 
wounds and the surrounding skin. It is too irritating to apply to the 
interior of wounds. 

10 



146 GUNSHOT WOUNDS 

In the present European War the virulent anaerobes have played 
a very disastrous role in the infection of wounds. The surgeons have 
relied especially on free drainage, aided by the use of mild antiseptics 
or normal salt solution to promote lymph lavage. In septic com- 
pound fractures it has become the rule to establish ample drainage, 
remove missiles, dirt, shreds of clothing, etc., found in the depths of 
the wound; to excise all necrotic and damaged tissues. When the 
wound is clean and drainage well established, it is packed with gauze 
impregnated with eupad or a eusol moist dressing is applied and main- 
tained by a drip. By these methods hypochlorous acid gas is generated 
deep in the wound and coming in contact with microorganisms, kills 
them. The antiseptic causes irritation of the skin which should be 
protected by applications of vaseline. The action of the antiseptic 
is very rapid, and for that reason it should not be used longer than a 
few hours lest irritation of the interior of the wound should occur. 

Professor Lorrain Smith (Brit. Med. Journ., July 24, 1915) gives the 
following directions for the preparation and application of hypochlorous 
acid in the form of eusol and eupad: 

"Hypochlorous Acid. — For use as an antiseptic the gas is most 
conveniently prepared by the action of boric acid on bleaching powder 
in the presence of a small quantity of water. The solution is obtained 
when the same action occurs in the presence of a large quantitiy of 
water. 

For convenience we have given the name 'eupad' to a powder 
consisting of equal weights of finely ground bleaching powder and 
powdered boric acid intimately mixed; while the solution of free 
hypochlorous acid prepared in this way we have named 'eusol.' 

Methods of Preparation and Chemical Notes. — To prepare eupad, 
ordinary commercial bleaching powder or chloride of lime is ground 
in a mortar to a fine powder, and then intimately mixed with an equal 
weight of boric acid powder. The mixture should be kept in closely 
stoppered bottles, and not exposed to light more than necessary. 

Eusol may be prepared by two methods: 

(1) Twenty-five grams of eupad are shaken up with 1 liter of water, 
allowed to stand for a few hours, then filtered through cloth or filter 
paper. 

(2) To 1 liter of water add 12.5 grammes bleaching powder, shake 
vigorously, then add 12.5 grammes boric acid powder and shake again. 
Allow to stand for some hours, preferably over night, then filter off, 
and the clear solution is ready for use. 



TREATMENT OF GUNSHOT WOUNDS 147 

This solution contains: 

Hypochlorous acid 0. 54 per cent. 

Calcium biborate 1 . 28 per cent. 

Calcium chloride 0.17 per cent. 

Total . 1.99 per cent. 

The hypochlorous acid is estimated by titration with N/10 arseni- 
ous acid solution; this method is best, as the presence of chlorates 
does not affect the result. 

"The chemical reaction involved in the preparation of hypochlo- 
rous acid by the method described may be represented by the following 
equation : 

2CaOCl 2 + 2H 3 B0 3 = 2HC10 + CaB 2 4 + CaCl 2 + 2H 2 0. 

If the reaction takes place in the presence of a large quantity of 
water, a solution of hypochlorous acid is formed; if little water is used, 
gaseous hypochlorous acid is given off. 

The hypochlorous acid in the form of a gas is more mobile, and will 
be absorbed by the tissues more rapidly and in larger quantity than from 
the solution; this will explain its greater efficiency as an antiseptic. 

A concentration of 0.5 per cent, hypochlorous acid has been found 
the most satisfactory. Stronger solutions may be prepared by this 
method, but no advantage is gained, as they rapidly lose strength, 
coming down to about 0.5 per cent, free acid, after which they decom- 
pose more slowly; for practical purposes a solution of 0.5 per cent, 
remains effective for from three weeks to a month. 

Methods of Use. — It is convenient to group these under an in- 
dependent heading. While we indicate those methods we have ob- 
served in use, there are no doubt others which experience will suggest. 

(a) Eusol. — Standard strength approximately 0.5 per cent, hy- 
pochlorous acid. 

(1) As a lotion; diluted, if necessary, with water or normal saline. 

(2) As a fomentation; covered with a water-proof. 

(3) On gauze wrung out of the solution and applied without a 
water-proof covering. 

(4) As a bath; full strength, or diluted as indicated. 

(b) Eupad. — Where it is desired to apply a more concentrated 
antiseptic, eupad may be employed as follows: 

(1) Eupad enclosed between layers of gauze or lint charged with 
water sufficient to moisten the powder; this is applied to the wound and 
covered with wool and a bandage. 



148 GUNSHOT WOUNDS 

(2) Applied as above, but covered with water-proof. This should 
be applied only for a short period — ten to twenty minutes as a rule. 
Occasionally this strong application causes pain, and, should this 
occur, a weaker application is indicated. 

(3) On strands of gauze or wool impregnated with the powder and 
used for drainage. 

(4) As a dusting powder — for example, on open septic sores. 
The general principle of the antiseptic application is that it should 

secure the maximum antiseptic effect with the minimum of local 
irritation. 

Where it is found desirable to increase the antiseptic effect of the 
solution, a little of the powder may be added to it just before it is 
applied, or a small amount of the powder may be dusted on to the wet 
gauze. In these ways the action of the solution may be reinforced. 

In conclusion we have to express our indebtedness to members of 
the surgical staffs of the hospitals to which we have referred for their 
kind co-operation and help in this investigation." 

Carrel 1 has modified the use of eusol somewhat. He believes the 
antiseptic to be too irritating to the skin and tissues in full strength. 
He believes also that the antiseptic action is of short duration and that 
it is impaired by contact with albuminous substances. He prefers 
to wash every cavity of the wound with a half strength solution. Per- 
forated drainage tubes are then placed in the remote recesses of the 
wound. In case of compound fractures the ends of the drainage tubes 
are carried to the area of fracture among the bony fragments. The 
wound is next filled with gauze and covered with non-absorbent cotton 
through which the ends of the tubes project. Eusol is then run through 
the tubes every hour, or continuous irrigations may be employed. 

Under Carrel's watchful care the less severe wounds become clean 
in a very few days and are brought together with adhesive plaster. 
Septic wounds from shell fragments and shrapnel balls become aseptic 
in about five days, and it is further stated that septic compound 
fractures, so treated, become clean, and heal like aseptic wounds. 

Treatment of Wounds by Saline Solutions. — The treatment of 
wounds as we know it today is not complete without reference to the 
important contributions of Sir A. E. Wright 2 on the use of salt solu- 
tion. Since the early part of the war, the observers have noted that 
antiseptics have failed in preventing sepsis or in disinfecting badly 

1 Dr. Alexis Carrel, Bulletin de l'Academie de Medecine, T. LXXIV., No. 40. 

2 Brit. Med. Jour., 1915, II, 629, 670, 717. 



TREATMENT OF GUNSHOT WOUNDS 149 

contused and infected wounds. According to Wright's idea the pa- 
tient's resistance is more potent in dealing with local infection than the 
various kinds of antiseptics. To develop this local resistance he first 
advises free drainage and next he endeavors to promote lymph lavage 
by the use of salt solution which stimulates a profuse flow of lymph, 
containing antibodies. The salt solution induces diapedesis thereby 
bringing a concentration of leucocytes in the tissues, which in a large 
measure overflow into the wound cavities. 

In badly infected wounds the microorganisms work their way into 
the adjacent tissues in a very short time depending upon the kind of 
organism and the amount of devitalized tissue. Infection is carried 
deeply in the tissues by the projectile, the dirty skin, and shreds of 
infected clothing. Unless there is free drainage in such a condition, 
the lymph in the deeper tissues becomes inactive. With its antibodies 
it serves as a pabulum to the microbes which it is attacking. By 
bringing hypertonic solutions of various kinds into direct contact 
with the surfaces of the wound, a species of Bier's hyperemia is induced 
which drains away the stagnant lymph and also the microorganisms. 

Hypertonic solutions are most useful in promoting the lymph 
flow. A 5-10 per cent, solution of sodium chloride is used, the exact 
strength to be determined by the amount of devitalized tissue present. 
After the wound has become free from septic matter, normal saline 
should be used. 

Saturated sodium chloride solution kills bacteria; a concentration 
of 2-5 per cent, will inhibit growth, and normal saline (0.85 per cent.) 
is only bactericidal to certain groups of microorganisms — its value in 
wound treatment lies in the fact that it stimulates emigration, and that 
it prevents bacterial growth by the prophylactic action of the leucocytes 
which permeate the walls of the wound and subsequently bathe its 
surface. 

The application of the method may be accomplished by — (1) 
constant irrigation; (2) by continuous bath; (3) by introducing tablets 
or salt sacks into the recesses of the wound. 

(1) Constant Irrigation. — Constant irrigation with a hypertonic 
solution will remove the film of septic matter which is prone to line 
the wall of the cavities in a wound. This may be employed by arrang- 
ing a continuous drip of saline solution on the gauze which has been 
placed in all parts of the wound. It is preferable to irrigation through 
drainage tubes, by which method the fluid merely runs in and out 
through the tube without coming in contact with the surfaces of the 



150 GUNSHOT WOUNDS 

cavity. The method may be modified by employing cigarette drains 
shown in Plate D, Figs. 2 and 3. The osmotic action of the hypertonic 
solution promotes a constant flow from the tissues into the wound 
which aids in washing away the film of toxic matter that would other- 
wise accumulate on its surfaces. 

In a septic compound fracture for instance, the irrigation may be 
recommended with a 5 per cent, saline solution and continued until the 
wound is found to be clean and the temperature has dropped to about 
100° F. A normal saline is now substituted for the stronger solution. 
In very bad septic conditions it may be necessary to commence irriga- 
tion with a higher concentration than 5 per cent. 

(2) Continuous Bath. — The bath treatment of wounds has again 
become popular. The explanation of its action is based on the increase 
of blood supply which a hot bath brings to the injured part. The 
method is not new, hitherto we have employed antiseptics of various 
kinds in the bath, but this has now been largely replaced by the hyper- 
tonic solution bath. The bath treatment is ideal for septic conditions 
of the fore-arm and leg. It may be alternated in the twenty-four 
hours with hot fomentations. The bath alone should not be used for 
a longer time than three or four days since it brings about a sodden 
condition of the tissues when used for a greater length of time. 

Salt Sacks. — This method is one of the evolutions of the hypertonic 
treatment of war wounds and it was first used by Colonel Gray, 1 
R. A. M. C, who uses it as follows: After the wound has been irrigated 
with a 5 per cent, salt solution, its cavity is packed with gauze wet 
with hypertonic solution of the same strength. In the folds of the 
gauze are placed here and there tablets of sodium chloride, being care- 
ful that the gauze only and not the tablets are allowed to touch the 
walls of the wound. The deep parts of the wound are drained by 
counter-openings or tubes made of perforated zinc or large perforated 
rubber tubing. The gauze becomes soaked with a saturated solution 
of sodium chloride, which causes a flow of lymph from the neigh- 
boring tissues into the gauze packing that separates the walls of the 
wound. 

In lieu of salt tablets, Gray has lately used salt sacks made as follows : 
The sacks are of suitable size, each with a double wall. The space be- 
tween the outer and inner sack is filled with four layers of gauze. The 
smaller interior sack is filled with salt, whilst the end of the interior sack 

1 General Treatment of Infected Gunshot Wounds. Brit. Med. Jour., 1916, I, 
by H. M. W. Gray, R. A. M. C. 



GUNSHOT WOUNDS 



Plate D 




[Hi 



ttr 



m 



t 




Fig. 1. Fig. 2. 

F IG i — The capillary properties of ordinary bandage will drain salt solution from one vessel 
to a lower as shown in the figure, at a rate of over a pint an hour. This is taken advantage of in 
the drainage of wounds by capillary drains. 

F IG . 2. Materials for making capillary drains. The rubber sheet and bandage are rolled 

around a strip of aluminum or wire in the form of a cigarette drain. A fine rubber tube is stitched 
to the drain. The drain is inserted into the wound to the required depth and then bent at a right 
angle flush with the surface of the limb. The bandage is about twelve inches long and passes from 
the cigarette drain to a basin of saline solution. By means of the fine rubber tube, drip irrigation 
is carried out. Several drains may be required in a large wound. 




gjKy^W t (• ( K iWT* 





GAl/Z/T FOUR rOLO 

BETWEEN 
OUTER 0ANDAG£ 

AND SAC 



Fig. 3. Fig. 4. 

Fig. 3. — Capillary bandage drain in use. The drain is retained in position by bending the metal 
support and strapping it to the limb. The smaller rubber tube provides continuous irrigation and 
the bandage drains by capillary attraction. The materials for making this cigarette drain are 
shown in Fig. 2. 

Fig. 4. — The upper figure represents the salt sack ready for use, the lower figure shows it in 
section. The gauze between the two layers of bandage which form its wall prevents the deleterious 
action of the solid salt upon the tissues. The bandage continuation of the sack provides capillary 
drainage. The sacks are packed and kept sterilized ready for use. They are dipped into salt 
solution before insertion: the soft moist salt allows the sacks to mould themselves to every crevice 
of the wound. 

From Surgery in War. By A. J. Hull. London & Philadelphia, 1916. 

Facing page 150. 



TREATMENT OF GUNSHOT WOUNDS 151 

is left long enough to protrude into a vessel containing saline solution. 
The sacks are made of different sizes, sterilized, and kept on hand. One 
or more may be used to pack a wound. Long slender sacks are made 
to fill channels of corresponding length. The sacks may be refilled 
through the distal end in the basin and they may be left in place for 
8 or 10 days. The method is simple, and by having the sacks previously 
prepared, it is possible for a limited personnel to dress a large number of 
wounded, and the wounded may be transported without the necessity 
of redressing en route. (Plate D, Fig. 4.) 

The hypertonic method of treating septic wounds is undoubtedly 
of much value. It is considered superior to the other methods 
heretofore used by those who have had experience with it. Those 
who have the opportunity should give it a fair trial. It no doubt re- 
quires experience to attain the best results. There is much detail 
about it which necessitates care and patience. 

We should not forget that this great war has emphasized anew the 
value of ample drainage in the management of septic wounds. 
Whether the hypertonic method is superior to the use of antiseptics 
like dilute iodine, boric fomentations, peroxide of hydrogen, carbolic 
acid or bichloride of mercury in the presence of complete drainage 
and pursued with the same amount of care and painstaking detail is 
a question which can only be answered by practice. 

Open Treatment of Wounds. — During the beginning of the present 
war a great deal was published on the value of treating septic wounds 
by the open method — without dressing with wool and bandage. The 
heavy dressing was looked upon as a breeding place for microorganisms, 
and instead the wounds were covered with a moist piece of gauze 
generally wrung out of salt solution. In some hospitals this is the 
favorite treatment at the present time. 

Treatment of Gunshot Wounds by Excision and Primary Suture. — 
We are indebted to Colonel Gray for another valuable contribution on 
the treatment of wounds in the present war. 1 Acting on the well- 
known fact that all gunshot wounds are infected, Gray does not wait 
until a widespread evidence of the septic condition has appeared. He 
promptly excises all the devitalized tissue which can be reached by the 
knife, the sooner after the injury the better, and he next closes the 
wound by primary suture. He claims that healing is assured in the 
majority of properly selected cases. Much time is saved. Wounds 
which would ordinarily require months to heal are thoroughly united 

1 Brit, Med. Jour., 1915, II, p. 317. 



152 GUNSHOT WOUNDS 

in the course of ten to fifteen days. There is a saving of time to the 
patient, the government, the personnel, to say nothing of the curtail- 
ment of pain. The amount of dressings is reduced to a minimum. 
Complications are avoided, the scar is lessened and there is less 
impairment of function. The author describes the steps and value 
of this treatment so well that we here quote his method from a recent 
issue of the Journal of the Royal Army Medical Corps: 

"The mere length of a wound is no bar to operation. Some very 
long wounds have been excised. A missile may inflict what resembles 
an incised wound and, because dividing the tissues at right angles to 
the line of their greatest tension, may, owing to the contractility of 
these tissues, cause a large gaping wound. In such cases there will 
be but little tension when sutures are inserted and tied, if too great a 
mass has not been excised. One can test roughly what the amount of 
tension will be by attempting to push the surfaces of the wound 
together. 

"It is not necessary to wait until the wound is surgically clean; in 
fact, in most cases the sooner the excision is made the better. The 
wound will probably be soundly healed in a shorter time than it will 
take to clean. During the ' cleaning ' process the adjacent parts 
become so softened that sutures do not hold well. Only when a large 
' bank ' of inflamed tissue surrounds the wound is immediate excision 
inadvisable on account of the septic condition of the wound. In such 
cases it is probable that organisms have penetrated to a considerable 
depth and will cause trouble when the tissues invaded by them are 
subjected to the pressure of sutures. By vigorous 'salting' (hyper- 
tonic treatment) such wounds are rendered suitable for excision in 
twenty-four to forty-eight hours. Other contra-indications are the 
presence of marked pocketing in the wound and the exposure of vascu- 
lar or nerve trunks in the depth or of bone which it is inadvisable or 
impossible to remove. 

"In any case excision of the soiled edges of skin and of the superficial 
connective tissue and muscle may be done with advantage. The 
healing process in the wound as a whole is thereby accelerated. 

"Certain bony prominences, such as a vertebral spine or the edge of 
the acromion process, may be capable of removal with the other 
infected tissues. The presence of pocketing in a wound is very im- 
portant. If part of such a pocket, or, indeed, if any septic focus be 
left, the operation will probably prove a failure. 

"The technique is, therefore, very important. The operation can 



TREATMENT OF GUNSHOT WOUNDS 153 

usually be done under infiltration anaesthesia of the neighboring 
parts. It is well to add plenty of adrenalin to the anaesthetic solution 
so that hemorrhage during the operation is avoided. Accurate hemos- 
tasis is important for success. 

"The parts around are shaved and disinfected very thoroughly. 
The wound is wiped out, dried, and packed with gauze. 

"For disinfecting purposes in these cases I favor the use of very 
strong iodine solution (5 to 10 per cent, in spirit of ether). This is 
painted thoroughly into every part of the wound and over the sur- 
rounding skin for a considerable area. It has the effect of drying the 
surface of the wound in a remarkable manner. The strong iodine is 
wiped off the skin with spirit of ether at the end of the operation. 

"The skin close to each extremity of the wound is caught up by a 
tissue forceps or a loop of thread and slight traction is made in a direc- 
tion away from the center of the wound at an angle of about forty- 
five degrees with the sound skin. The whole wound is then cut away 
en masse (skin, flesh, and if necessary, bone) at a distance of about 
one-third to one-half an inch from the raw surface. Care must be 
taken that pockets or general surfaces of the wound are not cut into 
during this procedure. Bony prominences are removed along with 
the soft parts by dividing them with bone-pliers, gouge-forceps or 
chisel. If the wound is deep it is sometimes of advantage to insert 
the finger into the wound as a guide to where the tissue must be 
divided. 

"A very sharp scalpel is invaluable. Cutting out the wound in 
pieces makes success precarious. 

The new wound surfaces should now be washed out with saline 
solution and packed with gauze, and the surrounding skin wiped free 
of blood or discharge. Fresh towels, fresh instruments, and if the 
wound has been handled, fresh gloves should now be used. 

"The wound should be closed by wide sutures which underrun its 
floor so that no dead spaces are left. It may be necessary to suture in 
layers. If so, the suture of each layer should include some of the tis- 
sue of the deeper layer. The skin should be accurately approximated 
by a few fine sutures. Further relaxation sutures are not often 
necessary. 

"The following dressing should then be applied. The line of sutures 
and the adjacent skin for several inches should be painted with a 
wound varnish, of which mastic, dissolved in some rapidly evaporating 
solvent, forms the important part (40 to 50 per cent.). When the 



154 GUNSHOT WOUNDS 

varnish has become "sticky" (after one and a half to two minutes), 
a covering of gauze, at least two layers thick, should be stretched 
tightly and smoothly over the sticky area, gently patted down, and 
cotton-wool and bandages applied fairly firmly. If it is desired to 
inspect the wound at any time, after removing the bandage and wool, 
the top layer or layers of gauze should be peeled off by traction at 
right angles to the surface, the layer next the skin and wound being 
at the same time retained by the other hand. Perfectly satisfactory 
inspection can be made through the single layer of gauze. The loose 
edges of the gauze should be neatly trimmed. In many cases no 
further dressing is required until the stitches are to be removed. The 
final layer of gauze is then peeled off. 

If fine catgut sutures have been used for the skin, it is often found 
that the knots come away with the layer of gauze, the deeper parts 
having been digested. A fresh application of mastic varnish and gauze 
should then be made and left until the wound is firmly healed. The 
varnish should on no account be painted over the gauze after it has 
been applied, otherwise the gauze cannot be peeled off as described. 
The varnish and gauze dressing is important for success. It is the 
best I know. It gives wide support, relieves tension and prevents 
any dragging on the stitches. These factors are of great value in 
preventing stitch abscess." 

Treatment of Virulent Infections. — The virulent infections which 
are intimately associated with war wounds are due to: B. tetani, 
B. aerogenes capsulatus, and B. of malignant oedema. The fatality 
from these infections was very great during the commencement of the 
present European War. The reduction in mortality is due to distinct 
methods in treatment, which deserve mention aside from the treat- 
ment of the ordinary infections. 

Tetanus. — The treatment of tetanus is prophylactic and curative. 

The Prophylactic Treatment. — Tetanus toxin is produced locally 
in the wound and it is from there carried to the nerves of the central 
nervous system, especially those of the medulla and pons. The 
tetanus toxin is one of the most powerful poisons known, 1 c.c. 
of the filtrate of a broth culture being enough to kill an average sized 
guinea-pig. 

Infection may occur in a trivial wound, but generally it appears 
by preference in those who are injured by shell fragments, or rifle 
wounds delivered at close range, when the wound area is the seat 
of contusion, devitalized tissue and hematoma. In any degree 



TREATMENT OF GUNSHOT WOUNDS 155 

of injury there must be first the presence of the infection, and next 
there must be trauma of the tissues, effusion of blood, and devitalized 
tissue to promote the development of tetanus. In other words, tetanus 
is not likely to develop in a clean incised wound. In such a wound, if 
the bacillus of tetanus is present, it exhibits none of the clinical evi- 
dences of the disease, unless perchance pyogenic microbes devitalize 
the tissues, and then the bacillus of tetanus which is a typical sapro- 
phyte, commences to multiply unduly and to elaborate toxins, follow- 
ing which all of the clinical symptoms of the disease appear in rapid 
succession. 

Tetanus antitoxin is obtained from immunized horses in very 
much the same way that we obtain diphtheria antitoxin. The 
strength of a given tetanus antitoxin is determined by the amount 
which is required to protect a given weight of animal against the 
simultaneous injection of a lethal dose of toxin. For instance, 1 c.c. 
of the Pasteur Institute antitoxin will protect 1,000,000,000 grammes of 
mouse against a lethal dose of toxin. 

In a case of diphtheria, the diagnosis is made promptly, before any 
of the constitutional symptoms of the disease have appeared, by 
microscopic examination of cover slips prepared from the infected 
area. Early dosage with diphtheria antitoxin will arrest the develop- 
ment of the disease in the vast majority of cases. In dealing with a 
case of tetanus the advantage of an early diagnosis is lost since the 
detection of the tetanus bacillus in the wound area is extremely diffi- 
cult. It too often happens that the presence of the tetanus bacilli 
in a wound is only ascertained after the characteristic symptoms of 
tetanus have appeared. It is then too late to neutralize the toxin 
which has become fixed in the nerve cells, by the administration of 
antitoxin. 

Acting upon the value of the prophylactic dose, the surgeons in the 
present European War administer at once a prophylactic dose of tet- 
anus antitoxin in all wounds of the extremities, deep wounds, and body 
wounds having much lacerated tissue. When it is possible to make a 
microscopic examination of the discharge from the wound, the prophy- 
lactic dose is not dependent upon the presence of the B. of Nicolaier 
which is difficult to find, but more upon the presence of other anae- 
robes easily identified with which it is constantly associated, like 
Bacillus aerogenes capsulatus and B. of malignant oedema. Their 
presence is an invariable determining factor in favor of the immuniz- 
ing dose. Now that the foregoing has become the routine plan of 



156 GUNSHOT WOUNDS 

treatment, tetanus, which was formerly seen with great frequency in 
war wounds, is now very rare. 

The wound should first be cleaned, drained and dressed with a 
view to minimize the danger of sepsis, in the way already recommended 
in these pages. A preventive dose of 500 units of antitoxin should then 
be administered subcutaneously at a distance from the wound, and 
the fact should be noted on the diagnosis tag. In severe wounds with 
much soiling, it is in order to administer 1500 units. 

Curative Treatment. — When tetanus has made its appearance there 
is little hope of destroying the combination between the toxin and the 
nerve cells. The union has taken place, and is still taking place in 
all probability. The idea of curative treatment is based on the sup- 
position that there is a certain amount of free toxin in the central 
nervous system which it may yet be possible to neutralize by the ad- 
ministration of antitoxin. If this is true, and the amount already 
fixed in the nerve cells is short of a lethal dose, there is hope that the 
patient may be cured. 

It is generally admitted by observers that no plan of treatment 
except the injection of antitoxin possesses any value. The earlier 
after the onset of symptoms the treatment is commenced the more 
likely will cure take place; it must be given in large doses, often re- 
peated until definite signs of cure are noted, and the remedy must be 
kept up in smaller doses and less frequently to prevent relapse. 

Dosage. — (1) Three to five thousand units are injected into the 
lumbar region of the spinal cord, under an anesthetic by preference, 
the volume of the fluid being brought up to 10-15 c.c. by the addi- 
tion of sterile normal saline, the exact amount being regulated by the 
age of the patient and the amount of spinal fluid withdrawn. 

(2) Ten thousand units are used intravenously at the same time. 

(3) The intraspinal dose should be repeated in twenty-five to 
thirty-six hours. 

(4) Administer 10,000 units subcutaneously, three or four days 
later. 

(5) Observe quiet, subdue light and use sedatives as indicated. 
The subcutaneous injections should be kept up in smaller doses and 

at less frequent intervals to prevent relapse as soon as the symptoms 
of cure are manifest. 

By the foregoing treatment, which is the method adopted by sur- 
geons pretty generally, M. Nicoll, J. Am. Med. Ass., LXIV, p. 1982, 
1915, gives the results in twenty cases as follows: The incubation 



TREATMENT OF GUNSHOT WOUNDS 157 

period ranged from seven to eleven days; sixteen of the twenty cases 
got well. The mortality, which is practically 100 per cent, under other 
methods of treatment, was reduced to 20 per cent, by the intraspinal 
method. The intracranial injection method is no longer advocated. 

Emphysematous Gangrene. — This form of gangrene, which has 
long been known by other names such as Traumatic Spreading 
Gangrene, Gangrene Foudroyante, etc., is by common consent attrib- 
uted to the Bacillus aerogenes capsulatus, although the mixed in- 
fection with Bacillus of malignant oedema and other anaerobes as 
well as pyogenic cocci which are usually present, plays some part in 
the pathologic process. There are several forms of the disease, but 
they are more likely stages of the same process, or degrees that are 
influenced by local and general resistance. 

As a guide to the methods of treatment to be employed the follow- 
ing forms will be noted. 

(1) Localized gangrene. 

(2) Emphysematous cellulitis or gaseous gangrene. 

(3) Gangrene of the limb. 

(1) Localized Gangrene. — This form occurs around a septic wound, 
very often a compound fracture. It is marked by a local cellulitis 
with the presence of gas bubbles in the discharge coming from the 
wound. The skin in the immediate vicinity of the wound is dusky 
red or brownish and crepitation is easily elicited by pressure at a short 
distance from the discolored area. 

The case may show no tendency to spread, or it may be influenced 
by a state of mixed infection and pass into emphysematous cellulitis 
or gangrene of the limb. The fluid which exudes from the wound is 
extremely foul, containing gas bubbles, while typical pus is absent. 
An orange colored discharge which is prone to stain the dressings is 
sometimes present. In some cases the wound secretes pus, or a dis- 
charge containing gas bubbles, without evidence of gas in the sur- 
rounding tissues. 

Treatment. — When treated early and radically, these wounds 
yield to treatment in the vast majority of cases. All devitalized tissue 
should be excised, the wound thoroughly cleaned by the ordinary 
methods of treatment, and effective drainage established. Multiple 
incisions down to, and through the cellular tissue, should be made in 
the infected area, and under the hypertonic treatment the case will 
generally end in recovery. As a guide one should mark the discolored 
area, and if the treatment is not successful and the disease process 



158 GUNSHOT WOUNDS 

shows a tendency to spread, amputation should be performed. Some- 
times free incisions of the calf will reestablish the circulation in the foot, 
but if the pulse behind the ankle remains absent and the foot continues 
cold and numb, amputation should no longer be delayed. 

(2) Emphysematous Cellulitis or Gaseous Cellulitis. — This form 
may show a tendency to remain local, but more often it spreads rapidly 
and ends in death unless amputation is promptly employed. 

When the tendency of the disease is to remain stationary, the 
measures of treatment mentioned already are successful in the majority 
of cases. 

In the diffuse variety of the disease the cellulitis involves a limb 
in a short time and then spreads to the trunk. When the portal of 
entry is in a compound fracture, and especially fracture of the femur 
the outcome is not hopeful. As already stated the skin around the 
wound is discolored, while the skin at a distance remains unaltered. 
The limb is swollen from cedema and the infiltration of gas and the 
crackling common to surgical emphysema is present. The develop- 
ment of gas precedes the development of cellulitis. Rapid pulse of 
small volume and the other evidences of profound toxemia are noted. 
Vomiting and hiccough are often present. Notwithstanding the serious 
condition of the patient, he is often placid, and shows none of the dis- 
tress which usually attends a grave illness. 

The wound, as in the more local form, should be thoroughly 
cleaned, lodged missiles and loose fragments of bone should be removed 
and all devitalized tissue should be cut away with scissors, and tissue 
exhibiting cellulitis should be freely incised. The wound should then 
be thoroughly drained and dressed after the hypertonic method, with 
the Dakin solution, or by the well-known surgical procedures which 
adhere to weak antiseptic solutions and frequent redressings. 

If the gaseous cellulitis continues to advance, and the circulation 
in the limb is interfered with as shown by the absence of pulse in 
the hand or foot with persistent coldness or numbness of the latter, 
immediate amputation should be employed. 

(3) Gangrene of the Limb. — In this form the gaseous process 
spreads rapidly and the limb dies en masse in twelve hours from a time 
when it was considered healthy. The patient exhibits the symptoms of 
profound toxemia due to absorption from the infected tissue. The 
temperature is subnormal or but slightly elevated; the pulse is of low 
tension and rapid; the extremities are cold, and there is often great 
pain in the limbs, the patient being alert rather than dull. 



TREATMENT OF GUNSHOT WOUNDS 159 

The entire limb is swollen and tense from the liberation of gas and 
fluid in the tissues, the hand or foot is pulseless, cold and numb. The 
skin is grayish white at first and then shows the usual discoloration 
into green, yellow, purple and black. The infection most generally 
originates in the seat of a compound fracture. The formation of gas 
rapidly spreads to the cellular tissue beyond the gangrenous area be- 
neath the skin and along the course of the great vessels. 

Treatment. — In cases of gunshot fractures the invasion of gas 
bacillus infection is extremely fatal. The surgeon should be on the 
alert and amputate promptly before the skin changes mentioned have 
set in and before the patient is overwhelmed with toxemia. Amputa- 
tion should be done by a circular flap in the skin down to the muscle 
above the infected tissue, and when the skin has retracted completely 
the circular incision should be continued at the point of retraction to 
the bone and the amputation completed. 

Some of the military surgeons employ infiltration anaesthesia to 
reduce the amount of shock to the minimum. Infiltration along the 
proposed skin incision with novocain and adrenalin is a favorite 
method. 

No sutures are used in the flaps, the surface is allowed to remain 
wide open to secure complete drainage. The parts are loosely packed 
with gauze soaked in hypertonic saline solution, and later constant 
irrigation is employed. 

Exploration of Gunshot Wounds. — The old-time method of ex- 
amining gunshot wounds with bullet detectors and probes of various 
kinds has been made obsolete, in military surgery at least, by the use 
of the steel-clad bullets that do not lodge as often as the old leaden 
projectiles. Again we depend upon the use of the X-ray to locate 
lodged missiles of all kinds and to interpret bone lesions, which often 
determine the necessity for or against operation. The rule of cutting 
down in all cases of gunshot injury for diagnostic purposes is unneces- 
sary. The position of the fragments can be ascertained by a study of 
a Rontgen ray plate for all practical purposes. As long as the wound 
remains aseptic the fragments of bone will retain their vitality and 
they will serve a useful purpose in the healing process. There are 
only two indications for cutting down upon a gunshot wound. The 
first is in the case of a lodged missile after its location by the X-ray, 
and the second is in case of gunshot fractures when infection has 
appeared or is threatened by the presence of many loose fragments. 



160 GUNSHOT WOUNDS 

Removal of lodged missiles more properly belongs to the Remote 
Treatment and it will be dealt with under that head. 

The author has purposely withheld comment on the different 
bullet detectors and extractors because their use is not contem- 
plated in the modern treatment of gunshot wounds. Nelaton probes 
seldom have application as detectors because the projectiles now are 
made of hard metals which leave no mark on the porcelain tip. The 
telephone probe is uncertain in its mechanism and often misleading. 
Bullet extractors are superfluous and their place is easily filled by the 
many different forceps in the armamentarium of the surgeon. Ex- 
traction of a bullet through the track which it has made should be 
avoided in all cases. To tamper with these already contused and lac- 
erated tissues only spreads existing infection and it adds to the danger 
of systemic infection by breaking up the lymph barriers that nature is 
establishing to prevent it. If it is necessary to remove the projectile, 
in the intermediate stage, after it has been definitely located, it is 
better to cut down de novo under strict antiseptic precautions and thus 
remove the projectile from its place of lodgment. Our experience 
following the battle of Santiago demonstrated that the patients them- 
selves were restless until the lodged missiles were removed. In this 
battle 10 per cent, of the rifle-bullet wounds had lodged balls, a fact 
that was explained largely by the uneven topography of the terrain, and 
an abundance of underbrush between the opposing armies. The major- 
ity of the projectiles removed gave evidence of indentation or other 
deformation from ricochet. We were short of dressings in the extreme, 
and the orders were to refrain from removing lodged balls except in 
cases of actual necessity, an order which we regret to state was not 
always complied with by the operating staff. 

Treatment of Hemorrhage. — As stated already, severe external 
primary hemorrhage of the kind that requires ligation of vessels, from 
present-day rifle bullets, is uncommon. It was not common with the 
old armament and it is thought to be less so with the new. Of the 
1400 wounded at the battle of Santiago no death from external pri- 
mary hemorrhage was recorded and no vessel was tied on the field to 
arrest this kind of hemorrhage. The experience of the English sur- 
geons in the Boer War and the reports of Follenfant on the Russian 
side in Manchuria confirm the rarity of avoidable primary hemorrhage 
on the field. 

At the same time that this kind of hemorrhage is specially rare 
with our present armament, as we will explain when treating of 



TREATMENT OF GUNSHOT WOUNDS 161 

aneurysm and injury to blood-vessels, injury to the latter is more 
often seen. The vessels are often grazed, their coats are partially 
destroyed and the remaining support gives way causing a hemorrhage 
later. These cases occur in the intermediate stage of the manage- 
ment of gunshot wounds, and they are to be dealt with at the field or 
base hospitals. Here also we are apt to have cases of recurring hem- 
orrhage in wounds where the temporary obstruction, like interven- 
ing layers of tissue or clot, gives way with the recurrence of bleeding. 
Most generally these cases have to be treated by ligation, an operation 
which can be more properly performed at a field hospital where the 
necessary facilities and trained assistants are at hand. 

Secondary Hemorrhage. — Thanks to antisepsis secondary hemor- 
rhage is now comparatively rare in war hospitals. As this form of hem- 
orrhage is mostly due to the invasion of septic organism into wounds, 
it was common in preantiseptic days and it caused great mortality. 
With our present methods of dressing wounds, we prevent sepsis, and 
it may be said that secondary hemorrhage from septic conditions is now 
as rare as it was common before. However, the traumatism incident 
to the mechanical effects of a bullet traversing soft and bony tissues 
will leave conditions at times that cause secondary hemorrhage inde- 
pendently of sepsis: (a) a spicule of bone adjacent to a vessel, in 
transport may, by its pointed, irregular or jagged edge, lacerate or cut 
an artery and thereby set up hemorrhage; (b) a vessel's coats may 
not be entirely cut away, and here again the hurtful effects of enforced 
transport are seen. A vessel whose coats are cut away, excepting 
the intima, should be kept as quiet as possible, but the emergent 
conditions in war often compel transport, and the jolting and jarring 
in all kinds of vehicles, over rough roads, tend to cause hemorrhage by 
rupture of the remaining barrier. 

The treatment of secondary hemorrhage is (a) by ligation of the 
vessel in the wound, (b) by ligation of the main artery of the limb, 
(c) by amputation. 

When secondary hemorrhage first takes place a tourniquet should 
be applied and an antiseptic tampon should be packed in the wound 
under firm pressure. As soon as proper preparations have been made 
the surgeon should open up the wound under antiseptic precautions 
and search for the bleeding vessel with a view to its ligation. In 
securing the vessel the surgeon should satisfy himself that he is 
applying his ligature to the healthy part of the vessel wall, because the 
coats of an artery in septic cases are apt to undergo slough, like the 



162 GUNSHOT WOUNDS 

rest of the tissues. The wound should next be thoroughly drained 
and cleaned by irrigation with antiseptic solutions like mercuric 
chlorid 1^1000, carbolic acid 1-40, etc. 

In those cases in which the bleeding vessel cannot be found, or 
where there seems to be oozing from one particular locality the actual 
cautery is indicated. The same resource may be employed where it 
is difficult to find a healthy vessel to tie conveniently. The latter 
may be seared with the cautery at a point where it appears healthy, 
provided it is not too large. In wounds of the extremities the prac- 
tice is to cut down upon the main artery and tie on the proximal side 
of the wound. If hemorrhage still persists or if gangrene sets in, a 
misfortune not uncommon in the lower limb, amputation is next in 
order. Proximal ligations succeed better in the upper extremity, but 
the rule there also is to amputate, if the hemorrhage recurs after 
ligation. Amputations are often performed in military hospitals 
under these circumstances, because of exigencies in military practice, 
which might be avoided in civil hospitals where the surgeon has entire 
command of the environments. To persevere and temporize in the 
military service means time, dressings that are often scarce, and attend- 
ants whose services are necessary for the alleviation of suffering to a 
greater number of wounded. Under such circumstances it is the 
safer course for the sake of the one whose limb is in jeopardy to 
amputate, and dress, rather than to persist under difficulties, with 
no assurance of succeeding perfectly. The harm that may be done 
to one wounded is compensated for by the greater amount of good that 
comes to those who might be otherwise neglected. 

Whenever it is possible to command the movements of patients 
it is better to keep the serious cases, at least, as quiet as possible. 
Those who have lost blood and who have sustained operations should 
receive supporting treatment of a special kind. 

Remote Treatment. — In the later or chronic stages of gunshot 
wounds it often becomes necessary to operate for removal of foreign 
bodies after their location has been definitely ascertained by X-ray 
examination. The removal of necrosed bone, once the source of a 
great deal of protracted suffering in gunshot wounds, has to be prac- 
tised occasionally nowadays, in old wounds, as a result of infection 
which persists or recurs from time to time. 

The correction of deformities and restoration of loss of function 
from injury to certain anatomical parts will come in for a certain part 
of the after-treatment, such as plastic operations to correct deformities 



TREATMENT OF GUNSHOT WOUNDS 163 

following cicatrization of extensive wounds and burns, and the restora- 
tion of function by the operation for severed tendons and nerves. 
Of the many disabling and remote consequences of gunshot injuries, 
the lodgment of foreign bodies is probably the most common. These 
are to be removed by surgical operation whenever practicable. 

After-treatment of Wounds. — The following so-called twelve 
commandments for the prevention of crippling have recently been 
published by the German War Office, and they are placarded in the 
battle and hospital zone of Germany: 

1. Remember that rest for joints (stiffness) and muscles (atrophy 
and loss of strength) is injurious. 

2. Do not depend that, after the tissue lesions have healed, im- 
paired motion can be overcome by orthopedic or medicomechanical 
after-treatment, but seek with all means at your disposal to prevent 
it and in grave cases refer the patients for after-treatment as soon as 
possible, in order that much time, effort and money may be saved. 

3. Confine fixation of the joints to a minimum and strive frequently 
to interrupt it as soon as the healing of the wounds and fractures per- 
mits (change angle of position, motions). 

4. Preserve as much as possible the precious strength in muscles 
jeopardized by rest, by early, regular massage, electrization, and, 
under your own supervision, by active motions by the patient himself, 
with and without external resistances. 

5. Bear in mind that extensor muscles succumb to atrophy much 
sooner than the flexors. Strive of all things to preserve for the arm 
its elevator (deltoid muscle) and for the knee its extensor (quadriceps 
extensor), for it is their weakening that most seriously impairs the 
function of the affected limb. 

6. When the tissue lesions render protracted fixation unavoidable, 
place the joints in such positions that their eventual ankylosis will 
render it the least difficult for the affected limb to function, namely : 

The shoulder- joint in the usual position of rest secured by a sling. 
The elbow-joint at right angle. 
The forearm-joint in inward rotation (pronation). 
The wrist-joint in the over-extended position naturally assumed 
when writing or firmly closing the fist. 
The finger-joints slightly flexed. 
The hip-joint slightly flexed and abducted. 
The knee-joint slightly flexed. 



164 GUNSHOT WOUNDS 

The ankle-joint about at right angle and at slight inward rotation 
(supination). 

7. Prevent the hand of an arm resting in the sling from gravitating 
into the flexed position, for this favors ankylosis of the fingers in ex- 
tension and interferes with closing the fist. 

8. Maintain the motility of the fingers. Do not unnecessarily 
include them in dressings, and never omit to admonish the patient 
to save his fingers from stiffening by continual extensive movements. 

Preserve for the wounded his natural grasping apparatus, for an 
artificial hand is without sensation and therefore less valuable than a 
living remnant. 

9. Stimulate the circulation of the blood in bed-ridden patients by 
motions of the limbs, also deep respirations, for increased circulation 
of the blood lends the inner organs beneficial stimulation and increases 
the nutrition and regenerative powers of the tissues. 

10. Dispose of blood early extra vasated into the tissues by means 
of measures furthering absorption (elevation, massage, heat, alternat- 
ing douches, etc.), for coagulated blood acts as a constant irritant 
leading to adhesions in the organs of motion and, when present in 
large quantities, to the formation of masses of connective tissue. These 
latter, as a rule, cannot afterward be gotten rid of in all cases 
completely. Bear in mind that the blood and lymph circulation is 
interfered with more in the ends of the limbs and that spontaneous 
absorption must here, under all circumstances, be aided by artificial 
means. 

11. Do not consider it below your dignity to early seek the advice 
and aid of an experienced colleague in all doubtful cases and, where 
your own technical ability does not seem sufficient, for you will learn 
thereby, and the injured will profit by it. 

12. Do not despise the purely mechanical, for our motor apparatus 
is a marvellous mechanism. Only he is able to set in motion a, 
complicated machine, who knows its mechanism and is a good me- 
chanic himself. 



CHAPTER VI 

Gunshot Wounds of the (1) Head, (2) Face and (3) Neck 

1. Gunshot Wounds of the Head. — The ratio of gunshot injuries 
of the head to the total number of casualties in battle has always 
been relatively high, but it has increased very much with the 
rapidity and accuracy of fire of modern arms. According to Long- 
more the head and face offer a target area of 5.89 per cent, com- 
pared to the target area of the rest of the body. If men fought 
standing the percentage of head wounds to the total number of 
casualties would correspond very closely to the above ratio. In 
modern wars the tactician drills his soldiers to fight under cover 
as much as possible. As a consequence the head is exposed to fire 
longer and more often than the remainder of the body. Again, 
in siege operations and fighting from entrenched positions the head 
and upper part of the body are necessarily more often and longer ex- 
posed so that the ratio of head wounds is relatively higher among those 
defending fortified positions. ^.The Crimean War is cited by writers as 
a typical example of the effects of fighting behind entrenchments, and 
as a result 20 per cent, of all the gunshots treated were of the head, 
face, and neck) 

The Spanish-American War, in which siege operations figured 
but little, gives a fairly good idea of the frequency of head wounds in 
modern wars. In 4756 gunshot injuries in all parts of the body, the 
head, face and neck were injured in 15.26 per cent. 1 of the total. 
Fischer 2 gives 20 per cent, of head wounds for all gunshot injuries in 
the Manchurian campaign. 

Gunshot wounds of the head may be divided into (a) those of the 
scalp; (b) shot wounds of the skull without lesion of cranial contents 
such as, contusion, guttering and fracture of the outer or inner table 
alone; (c) shot fracture of the skull with attending brain injury. 

(a) Gunshot Wounds of the Scalp. — Contused or lacerated wounds 
of the scalp are rarely fatal. Out of 7739 scalp wounds by gunshots 
in our Civil War, Otis reported a mortality of 2.09 per cent. The 
fatalities are attributed to erysipelas, meningeal inflammation, gan- 

1 Annual Report S. G., U. S. A., 1900. 

2 Archives de Med. et Phar. Mil., No. 48, 1906, p. 102. 

165 



166 GUNSHOT WOUNDS 

grene, tetanus, pyemia, etc. Doubtless some of the fatal cases of 
wounds of the scalp, as pointed out by certain authors, include lesion 
of the skull that is not easily determined. Thus Chenu reports a 
mortality of nearly 10 per cent, in 1633 contusions and simple wounds 
of the scalp among the French troops in the Crimea. The divergence 
of the figures given by the two authors would indicate that a certain 
percentage of the French wounded had suffered from unrecognized 
cranial injuries. 

From present-day military rifle bullets, wound of the scalp per se, 
as a result of superficial glancing and grazing shots, should be attended 
with no mortality. Writers from the Boer War observe that grazing 
shots exhibited loss of substance, "the skin being actually carried 
away by the bullet" (Makins). Scalp wounds from shell fragments and 
shrapnel are irregular and lacerated. The wounds are larger as a rule 
than those made by the rifle bullet and they are more prone to in- 
fection. 

Treatment of Shot Wounds of the Scalp. — No class of wounds 
should receive greater care in the primary dressing than head wounds. 
The dirt of the scalp is constant, and no scalp wound escapes infection. 
The surgeon's aim from the first should be directed to minimize the 
amount of infection present in the wound. In active campaign and 
during other emergent conditions the surgeon has in tincture of iodine 
a great aid for the subjection or prevention of sepsis. The hair should 
be either shaved or cut as short as possible with scissors. Short 
subcutaneous tracts should be laid bare by connecting the wounds of 
entrance and exit. The adjoining skin and wound should be swabbed 
with a 50-per cent, solution of tincture of iodine, followed by the appli- 
cation of a first-aid field dressing. In field and base hospitals where 
all the facilities for wound dressing are at hand, thorough scrubbing 
with nail brush, soap and water and the liberal use of antiseptic solu- 
tions should precede the application of the primary dressing. 

(b) Shot Wounds of the Skull without Lesion of Cranial Contents. 
— In this class of injuries we have contusion of the skull with fracture 
of the outer or inner table alone. The following table from the 
Records of the Civil War by Otis is full of interest for a consideration 
of the subject of cranial injuries by gunshot in these days of clean 
surgery and the change in the implements of war. The table has 
served all writers in discussing head injuries since it was written, 
because of the richness of the material, and the masterly analysis of 
it by the great author. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



167 



GUNSHOT INJURIES OF THE CRANIUM 

Results of 4350 Gunshot Injuries of the Cranium Reported During the War of 

the Rebellion 



Injuries 


Cases 


Recov- 
ered. 


Died 


Undeter- 
mined 


Ratio of 
mortal- 
ity 


Contusions of the skull 


328 

138 

20 

19 

2911 

364 

486 

73 

9 

2 


273 

128 

1 

12 

1001 

231 

68 
14 

1 


55 
10 
19 

7 
1826 

129 

402 

56 

9 

1 


84 

4 

16 

3 


16.8 


Fracture of outer table alone (?) 

Fractures of inner table alone 

Linear fissure of both tables 

Fracture of both tables without 
known depression. 
Depressed fractures 


8.7 
95. 
36.8 
64.6 

35.8 


Penetrating fractures 

Perforating fractures 


85.5 
80. 


Ecrasement or crash or smash . . . 
Contf e-coup (?) 


100. 
50. 


Aggregates 


4350 


1729 


2514 


107 


57.7 



Contusion of the Skull. — The vast majority of contusions of the 
skull in former wars were inflicted by slow-moving lead rifle bullets. 
The change of the armament has rendered them less frequent in recent 
wars, and they will be the result henceforth of impact from shrapnel 
balls, slowly moving shell fragments, and spent rifle balls. In such 
cases the periosteum is lacerated and the bone is more or less 
contused. 

Fracture of Outer Table Alone. — Gunshot fracture of the external 
table of the cranium alone has been especially rare. The instances 
on exhibition in the vast collection of skull injuries from the Civil 
War in the U. S. Army Medical Museum, at Washington, relate to 
fracture of the outer table of the frontal sinus, the mastoid, and zygo- 
matic process of the temporal bone. Now and then a grooving of 
the outer table of the vault is found produced by the sharp angle of a 
shell fragment. Wherever injury to the outer table occurred in other 
regions of the skull, the inner table was also involved. What was 
true of this injury by the old armament is alike true of the same injury 
by the new. We have never seen a gutter fracture of the skull of 
the outer table, from jacketed bullets of reduced caliber in the living, 
or in cadavers from experimental shots, which did not show splintering 



168 



GUNSHOT WOUNDS 



^ 



of the inner table. This fact has also been noted by observers in 
recent campaigns although Stevenson and Makins each reports a 
case from the Anglo-Boer War. 

Fracture of the Inner Table Alone. — Gunshot fracture of the inner 
table alone, occurring from direct violence to the outer table, has 
been noted by military surgeons generally. Otis refers to ten speci- 
mens in the Army Medical Museum from the Civil War and the returns 
give account of twenty cases in all. Figs. 87 to 90. Makins saw no 
case of the kind in the Boer War. We have no knowledge of such an in- 
jury by the jacketed missiles of the present day. Of the twenty cases 
reported by Otis fourteen were caused by oblique impact of musket balls, 
four by shell fragments, and one by a buck shot. The velocities im- 
parted to projectiles in that day compared to those of the present time 
were low, the projectiles themselves were non-penetrating, obtuse 
bodies, with sufficient energy on impact to cause the outer table to yield 
temporarily with resulting fracture of the inner table. The superior 
velocity and penetration of the jacketed rifle bullets of the present 
day tend to fracture the outer and inner tables at the same time, 
and they penetrate the skull to an extent proportional to the amount 
of their remaining energy, 

(c) Gunshot Fracture of the Skull with Attendant Brain Injury. — 
In this class of wounds the inner or both tables have been fractured 
with injury to some of the cranial contents resulting. They are 
most important because of their fatality; the prompt and radical 
measures of treatment that are often necessary; and also on account 
of their complications and sequelae. 

Fatality of gunshot injuries of the cranium with concurrent brain 
injury has always been relatively high. Grouped as a whole in 
accordance with the plan in Otis' table, the fatality in the Civil War 
was 59.2 per cent., in the Franco-German War 51.3 per cent., and in 
the Spanish- American War and Philippine Insurrection 51.6 per cent. 

In the Anglo-Boer War Stevenson gives the results of head injuries 
as follows: 





No. cases 


Recovered 


Died 


Death rate 
per cent. 


Gutters 

Penetrations 

Perforations 


63 
13 
60 


51 

8 
37 


12 

5 

23 


19 

38.4 

38.3 






Totals 


136 


96 


40 


29.4 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



169 




Fig. 87. — Photograph of outer table of 
skull showing contusion without fracture 
by a conoidal musket ball. 



Fig. 88. — Inner table of same skull with 
fracture. A fragment an inch and a half in 
length and half an inch broad completely de- 
tached from vitreous table. Specimen from 
Civil War 1861-65. A. M. M. collection. 




Fig. 89. — Photograph of gun-shot con- 
tusion outer table of skull without fracture 
by a conoidal musket ball. 



Fig. 90. — Inner, table same skull showing 
fracture with depression opposite the point of 
contusion on outer table. Dura was lacer- 
ated. Specimen from Civil War, 1861-65. 
A. M. M. collection. 



170 



GUNSHOT WOUNDS 



For the Russo-Japanese War Follenf ant, 1 writing of the statistics 
in the Kharbine hospitals for 1904, gives a mortality of 29.5 per cent, 
in seventy-one gunshot fractures of the cranium with brain lesion, 
and a mortality of 10.2 per cent, in 263 fractures without brain injury. 
Doubtless the latter suffered brain lesion in a certain percentage of the 
cases as the mortality is rated too high for this class. In dwelling upon 
the rather low mortality, 29.5 per cent, and 29.4 per cent., among 
those who suffered with brain inj ury in these two recent wars, we have 
to remember that Kharbine and the English base were far from the 
front and that the statistics are culled from a restricted class. Per 
contra we have to account for our relatively high mortality, 51.6 per 
cent., in the Spanish- American War by citing the fact that our statis- 
tics were made up from all cases coming under treatment, a class 
without restriction as to time, the extent or location of injury. We 
have reason to believe that the Anglo-Boer War and Kharbine statis- 
tics refer only to cases that reached hospital care after the lapse of 
some days. 

Gutter Fractures. — This form of injury is especially common 
with the use of steel-jacketed bullets. The ogival headed bullets of 




Fig. 91. — Gutter fracture of first degree. The drawing does not show well the small fragments 
of bone usually carried from the margins of the depression by the bullet. (Makins.) 



this class travel in a straight line, they are not deflected like the 
old lead balls. In the minor degrees of guttering the outer table 
is grooved by the projectile, carrying away small bone fragments. 
As these particles of bone become displaced with great violence 
they take up part of the energy of the bullet and force themselves 
1 Op. cit. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



171 




into adjoining soft parts. The scalp is slit in superficial bone 
fractures, but the more frequent injuries are deeper, they exhibit 
oval wounds of entrance and exit which mark the limit of the 
bullet's track. The shock of impact is so violent in the deeper 
gutter fractures that the vibratory force invariably fractures the 
inner table and the amount of comminution it sustains is generally 
greater than that seen in the outer table. Gutter fractures of the type 
mentioned occur in all parts of the 
cranium, they are characteristic of 
jacketed bullet wounds, and under 
prompt and radical measures of treat- 
ment the prognosis is very favorable 
for head cases. The following dia- 
grams from Makins represent the 
different degrees of gutter fractures 
and superficial perforating fractures 
by the modern bullet. Figs. 91-96. 

Penetrating Fractures. — In this 
class of skull fractures there is a 
wound of entrance and no apparent 
wound of exit. The missile is gener- 
ally lodged within the skull unless it 
has, as sometimes happens, passed 
down the neck. Again a non-pene- 
trating lead bullet, impressed by low velocity, may have flattened 
and lodged against the skull, producing fracture in and about the area 
of impact, or it may have bounded back through the entrance wound 
in the scalp. 

Penetrating fractures were more common in the days of the old 
armament. The surgical records of the Civil War make note of 
486 cases with a mortality of 85.5 per cent. The majority died at 
once or soon after reaching field hospitals. Many cases of recovery 
with lodged balls within the cranium are reported, and some were 
reported to have been restored to duty with balls lodged in their 
cerebrum, "but the diagnostic details accompanying the histories of 
these cases are not sufficiently precise to invite the fullest confidence " 
(Otis) . Missiles were successfully extracted from within the cranium 
in eleven cases. In one instance the wounded was an officer who 
remained on active duty ten years afterward, while the others were 
discharged the service and placed on the pension rolls. 



Fig. 92. — Diagrammatic transverse 
sections of varying condition of bones in 
gutter fractures of the first degree. A, 
with no loss of substance; B, with com- 
minution. (Makins). 



172 



GUNSHOT WOUNDS 




Fig. 93. — Gutter fracture of the second degree. Perforating the skull in the center of its course. 
External table alone carried away at either end. (Makins.) 




Fig. 94. — Diagrammatic transverse sections of complete gutter fracture. A, external table 
destroyed, large fragment of internal table depressed. (Low velocity or dense bone.) B, comminu- 
tion and pulverization of both tables center of track. C, Depression of inner table (low velocity). 
(Makins.) 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



173 



Of thirteen cases of penetrating gunshot fractures reported by- 
Steven son from the Anglo-Boer War the bullet lodged in nine cases, 
with five deaths. Of the four who recovered, the bullet was extracted 
in three cases and remained lodged in one case. The latter is referred 
to as a "surgical curiosity." "Trooper M was admitted to No. 




Fig. 95. — Superficial perforating fracture. Illustrating lifting of roof at both entry and exit 

openings. (Makins.) 

13 General Hospital for a gunshot wound of the scalp. A shell had 
exploded within a few yards of him, and he believed he was hit on the 
forehead with a stone, but this proved to be incorrect. There was a 
small dry scab over the middle of the frontal bone, and beneath it an 
almost healed wound through which, however, a probe passed into 




Fig. 96. — Diagrammatic longitudinal section of fracture shown in Fig. 95. (Makins.) 

the cranial cavity. There were no brain symptons, and the man ex- 
pressed himself as being ' perfectly well.' Brain symptoms appeared 
on the sixth day; the temperature went up, the patient became very 
restless and quite unaccountable for his actions. A trephine was 
applied at the side of the wound; the dura was found lacerated; 
several loose pieces of bone were removed, and a drain put in. All 



174 



GUNSHOT WOUNDS 



symptoms disappeared and the case did well until the sevententh 
day. Signs of brain irritation then again set in, and there was evidence 
of pus under the scalp above the right ear: the scalp was incised, 
giving exit to a considerable quantity of pus. It was then discovered 
that there was a fracture of the skull at this situation and that the 
pus came from an abscess of the brain. The trephine was again 




Fig. 97. — Latest skiagram of John Gretzer showing present location of Mauser bullet in brain. 
Exposure made in 1912, thirteen years after injury. Army Med. School collection, Gibbs Labor- 
atory. Dr. Leon T. LeWald, X-rayist. 

applied, the abscess washed out and drained; complete recovery 
followed. A skiagram showed a rifle bullet at the base of the brain. " 

The following case from the Spanish-American War is of even 
greater interest since it is accompanied by a photograph and skiagram 
recently taken. 

"Case 14. — Penetrating, Mauser-bullet wound of brain; wound 
aseptic; bullet not removed. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 175 

' John Gretzer, Jr., private, Company D, First Nebraska Volunteer 
Infantry, wounded at long range, March 27, 1899, at Mariboa, Philip- 
pine Islands, by a Mauser bullet entering cavity of cranium, 3/4 inch 
above the supraorbital ridge and 1/4 inch to the left of the median 
line. There was total loss of consciousness during first few hours 
following receipt of the traumatism, with the exception of a few 
short intervals of semiconsciousness, at which time excruciating pain 




Fig. 98. — Photograph of John Gretzer, Jr., late Pvt. Co. "D," 1st Neb. Vol. Inf., taken thir- 
teen years after receipt of injury. Scar from wound entrance shows on forehead above inner 
canthus, left eye. Army Med. School collection. 

in the head was experienced. The patient was taken to the First 
Reserve Hospital at Manila, where he lay in bed for about four weeks. 
While in bed, he suffered extremely from pain in the head, most 
severe the first three days, moderating slightly at the end of the 
fifth week, becoming intermittent, greatly exaggerated on exertion, 
by heat, and especially by direct rays of the sun, exposure to which 
caused him to reel, stagger, and almost lose consciousness. At the 
present time (August, 1899), is still quite susceptible to direct rays 



176 GUNSHOT WOUNDS 

of the sun. First few days of illness were marked by extreme nausea 
and persistent vomiting; the slightest thing taken in the stomach 
would be rejected. The pain in the head increased the severity 
of these attacks. During early weeks of illness any exertion of the 
brain, as reading, caused pain in back of eyes and vertex of the head. 

" Returned to San Francisco with his regiment in August, 1899. 
Radiograph taken August 20 showed Mauser bullet embedded in 
left occipital lobe. 

" Condition October 1, 1899, six months after receipt of the 
injury: Occasionally has pain in the lumbar region, and describes it 
as being a " catch," lasting about five minutes at a time. Pain in 
the head, when present, is located a little anterior to parietal eminence 
on left side. There is no history of loss of power on either side, but 
a weakness is appreciated in the right arm and leg, and a slowness in 
response to mental impulse. This last is demonstrated in the act of 
writing; though the thought is perfectly clear, there is a slowness in 
the forming of the words. 

" Voice: Patient did not, to his knowledge, exercise this function 
for first two days of illness, but on beginning to do so, noticed a slight 
confusion of ideas, it being necessary to first clearly fix a thought before 
giving expression. There was also temporary loss of power to recall 
past events and names of companions. This returned with full 
clearness at other times. A slight confusion still remains. 

"Eye: Pain back of left eye more or less severe, and increased by 
use, and relieved by closing the lid. During confinement to bed 
following injury, patient tested vision of left eye by closing right. 
The vision was clear, but slight weakness and photophobia were 
noticed. Ptosis of left eye was marked during early weeks of illness. 
Aperture is now smaller than that of right eye. A slight diplopia 
was also present, a line of printing appearing double. Pupils are 
regular, but left slightly larger. Reaction to light and power of 
accommodation is noticeably decreased, especially in left eye. Visual 
field normal. No nystagmus. 

" Hearing is normal. Sense of taste more acute on right side, the 
anterior two-thirds of left side showing marked dullness. 

" Tactile sense seemingly slightly dull on right side. General 
sensation of right side not as acute as on opposite side. 

"Reflexes: Knee reflex very marked on right side, responding to 
touch above, as well as below the joint; the contact from finger causing 
a disagreeable tingling throughout the thigh. On left side, reflex is 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 177 

exaggerated, but not to such a marked extent. Wrist reflex marked 
on right side, causing a chronic spasmodic contraction of the fingers. 
Reflex absent on left side. Ankle clonus and patellar reflex absent. 
Cremasteric marked on both sides. Sphincters uninvolved at any 
period of illness; coordination good, though a slight uncertainty is felt 
on attempting to walk with the eyes closed. No epileptiform seizures. 
No disturbance of nutrition or bodily functions. 

"The patient later entered the mail service and returned to Manila 
on duty." — Reported by Major A. C. Girard, Surgeon, United States 
Army, General Hospital, Presidio. 

Mr. Gretzer is now employed as a clerk in the Post Office Depart- 
ment. In a recent letter he writes of his condition as follows: 

Post Office Department, 
Office of the Inspector in Charge, 
New York, N. Y., Oct. 13, 1911. 
Colonel Louis A. La Garde, 

Commandant, Army Medical School, 
Washington, D. C. 
My dear Sir: 

I am in receipt of your favor of the 9th inst. relative to gunshot 
wound of head, received by me during my army service in the Philip- 
pine Islands. I regret that I am unable to furnish you with a medical 
history of my case since leaving the Presidio General Hospital. 

I have not received medical treatment for my wound, as I realized 
aside from an operation but little relief could be afforded, and my 
condition has not justified that, inasmuch as a consultation of army 
surgeons at the Presidio Hospital decided that an operation would 
probably prove fatal. The symptoms from which I suffer as a result 
of bullet carried in brain are about the same as when discharged, except 
stooping causes severe pains in the head. This is also true of a sudden 
jar. My wound appears to be affected by a change in weather. 
General health good. 

I will be pleased to furnish you any further information desired, 
and appreciate the interest you have taken in my case. I am 
enclosing a couple of newspaper clippings in connection with my case, 
which may be of interest. 

Yours sincerely 

(signed) John Gretzer, Jr. 



12 



178 GUNSHOT WOUNDS 

The following case exhibiting a lodged Krag-Jorgensen bullet is 
taken from the records of the hospital Madison Barracks, New York: 
J. S. Powell, Pvt. "K" Company, 9th U. S. Infantry, aet. 28, admitted 
July 23, 1903. " Accidentally shot by firing party at 500 yards range, 
ball ricocheting on butt timber and striking patient while in target pit 
at Stoney Point Rifle Range, New York, July 23, 1903, as per transfer 
slip." 

Diagnosis at Hospital. — " Gunshot fracture skull, right parietal 
region, Krag-Jorgensen bullet, severe, causing partial hemiplegia, 
left side. Entrance wound 4 inches above right external auditory 
meatus and 4 inches from right external angular process of frontal 
bone, ball penetrating brain, no exit wound.' ' Under chloroform 
anesthesia numerous pieces of bone were taken from the entrance 
wound, a bleeding vessel was ligated; brain lacerated, bullet not 
found. Scalp wound was sewed with silkworm gut and dressed anti- 
septically. Sent to quarters August 23. The patient was later dis- 
charged from the service, but he was readmitted to the same hospital 
June 3, 1904, for cerebral abscess posterior part parietal lobe. He died 
the same day. At autopsy ball was recovered on the tentorium in 
the position indicated in the skiagram, Fig. 99. After discharge from 
the service Jan. 28, 1904, the patient suffered from partial paralysis 
left side face, and left hand; headache, and vertigo, for which he was 
borne on the pension rolls until his death June 3, same year. 

The vital parts of the brain are sensitive to all projectiles, large or 
small. The following case exhibits the effects of a diminutive bullet 
impressed with comparatively low velocity when traversing the brain 
at the base: 

Fig 100 is from a skiagram which shows a .22-caliber lead bullet 
lodged in the brain substance. It was fired from a target rifle with 
suicidal intent by Corpl. C. 29th Company Coast Artillery Corps, 
U. S. Army. The muzzle was held against left temple. The ball 
entered 2 cm. above middle of left zygoma; traversed the left tem- 
poral lobe, left crus, corpus callosum and right parietal lobe, re- 
bounding from right parietal bone, it lodged in the posterior horn 
of the right ventricle. The original cartridge was a .22 short rim-fire 
lead bullet, weight 29 grains, velocity of 969 f.s. The deformed bullet 
as shown in Fig. 100 weighs 27 grains. The patient never regained con- 
sciousness and died in five hours from compression due to hemorrhage. 

Perforating Fractures. — These fractures are extremely fatal in 
war. The majority of the cases never live to reach field hospitals. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 179 

Otis fixes the mortality of those treated in the hospitals in the Civil 
War at 80 per cent. Of seventy-three cases only fourteen survived 
to be discharged and placed upon the pension rolls. It goes without 
saying that the fatality of perforating fractures of the skull is as great 
to-day with the use of the present armament, when the ball traverses 
the vital parts of the brain, as it was formerly with the old armament. 
At the battle of Santiago we found that the shots traversing the pos- 
terior two-thirds of the skull vertically, obliquely, or transversely 




Fig. 99. — Skiagram in case of Pvt. J. S. Powell, Co. "K" 9th Inf., showing a Krag-Jorgensen 
bullet lodged on the tentorium. Army Med. School collection X-ray Laboratory. 

near the base, were uniformly fatal, and that the amount of lesion 
and fragmentation were proportional to the remaining velocity and 
energy of the bullet. 

The so-called explosive effects of the modern military rifle are 
strikingly exhibited in perforating fracture from proximal shots 
on the skull. Explosive effects have often been reproduced ex- 
perimentally on inanimate matter, like containers of tin or sheet 



180 



GUNSHOT WOUNDS 



lead, filled with water, starch paste, etc. In the human body the skull 
with its rigid walls and semifluid contents approaches nearest in point 
of resistance to the containers of the experimenters, and the force which 
causes the remarkable lesions by the small bullet in certain wounds of 
the head is the same as that which swells and forces apart the walls 
of the containers. (See Figs. 69 to 74.) 

The power of our present military rifle in the living in producing 
typical explosive effects is shown in a case of suicide recently reported 

by Lieut.-Colonel Charles Wilcox, 
Medical Corps, U. S. Army. The 
present bullet, as already stated, 
is jacketed, pointed, length 1.08 
inches, 30-caliber, weighing 150 
grains, initial velocity 2700 f.s., 
energy at the muzzle, 2400 foot- 
pounds. The weapon ranks among 
the most powerful military rifles in 
present use. 

Patrick Dolan, Co. "K" 27th 
U.S. Infantry, shot himself Novem- 
ber 13, 1911. The muzzle of the 
piece was probably held in his 
mouth or near it in a direction from 
base to vertex of the skull. The ex- 
tensive destruction of soft parts 
obliterated all semblance to a 
wound of entrance or exit. The 
photographs show extensive destruction. The face above the lower 
jaw; the entire cerebrum and cranial vault were blown away. "The 
entire squad-room, especially the ceiling, was stained with blood 
and fragments of brain." The reporter very properly adds: "If 
this body had been found on a battlefield after an action in which 
artillery fire had played a part it would undoubtedly be assumed and 
with good reason that the head had been carried away by either a 
large projectile or a large fragment of the same." Figs. 101 and 102. 
In the case cited, doubtless, the force of the expanding gases, 
liberated at the time of the escape of the bullet, added to the ex- 
plosive effects, but aside from the pressure exerted by the gases we 
know that the energy of the projectile itself as well as that of the 
secondary missiles, like pieces of bone, dura and particles of brain 




Fig. 100. — 1. A .22 cal. bullet lodged in 
brain as indicated by arrow. 2. Photograph 
of bullet removed. Army Med. School collec- 
tion. Letterman Hospital, X-ray Laboratory. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



181 



matter, which became animated with part of the energy of the pro- 
jectile at the time of impact, assisted materially in the production 
of destructive effects. 

The bone lesion in a transverse shot at the base of the skull at an 
average battle range is exhibited in Fig. 103, a specimen from the 
Army Medical Museum, which shows the effects of an experimental 




Fig. 101. — Photograph showing side view in case of Patrick Dolan. 

Ft. Sheridan X-ray Laboratory. 



Army Med. School collection. 



shot in a cadaver by the same ammunition as that noted in the pre- 
ceding case. The bullet was impressed with the simulated velocity 
at 900 yards. It key-holed in the head of the barrel of saw-dust 
which was placed behind the target. In turning the ball struck the 
inner table of the skull side on, which no doubt added to the size of 
the wound of exit in the scalp, and helped to fissure and comminute 
the bony vault as shown in the figure. There was extensive lacera- 
tion of brain tissue on the exit side, which was no doubt due to the 



182 



GUNSHOT WOUNDS 




Fig. 102. — Posterior view of Fig. 101. 




Fig. 103. — Photograph shows an experimental shot fracture of skull, of cadaver, brain in situ, 
by the pointed bullet .30 cal. Springfield rifle, simulated velocity at 900 yards; wound of entrance 
over left temporal bone, size and shape of bullet; wound of exit irregularly round, 1 inch diameter. 
No. 14180 Pathological Series. Specimen from the A. M. M. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



183 



direct transmission of part of the bullet's energy to the brain parti- 
cles which were themselves shot forth with violence against the bone, 
thus adding to the destructive effects. The skull as a whole shows 
more Assuring than is usually seen in a gunshot fracture with the re- 
maining velocity at 900 yards. The subject was past sixty years, and 




Fig. 104. — Army Medical Museum collection. No. 10910 pathological series. 

no doubt the brittle condition of the bones of the aged figured in the 
amount of fragmentation. In war the subjects are young men as a 
rule and the bony lesions are not so marked. 

Figure 104 shows the appearance of a poster o-anterior injury in 
the living, near the vault, by the Krag-Jorgensen bullet at close 
range in the case of a prisoner who attempted to escape from the guard. 
The bullet was .30 caliber, jacketed; weight 220 grains, ogival- 



184 GUNSHOT WOUNDS 

headed with an initial velocity of 2000 f.s. It is the Krag-Jorgensen 
bullet which was used by the U. S. Army until 1906. x The victim 
was 90 feet from the rifle when hit. He was running from the guard at 
the time. The wound of entrance was in the occiput and that of exit 
in the frontal region as shown in the figure. " After passing through 
the man's skull the ball penetrated a tree 8 inches in diameter and 
buried itself in the ground 2 feet. The man lived one hour. The 

wound of entrance in the skin presented a round opening 

The wound of exit in front 

was larger and more ragged. The integument was carefully dissected 
off and the bone at the top of the skull found extensively fractured, 
the parts being here and there connected by fascia. On the calvarium 
being removed the surface of the dura mater presented a state of in- 
tense congestion. To the right of the longitudinal fissure it was torn 

through for a distance of about 4 inches On removal of 

the coverings the convolutions of the brain were made prominent 
by the engorged network of superficial veins. A furrow corresponding 
to the injury of the dura was ploughed through the right hemisphere 
in the region of the superior frontal convolution about 1/2 inch deep. 
The right lateral sinus appeared filled with blood serum, the left was 
normal. After removal of the brain the cribriform plate exhibited 
comminuted fracture; one or two slight fissures in the petrous and 
squamous portions of the temporal bone, otherwise the bone was 
intact. " 

The explosive effects would have been more marked had the 
projectile entered nearer the base and penetrated where the maximum 
resistance in the skull was located. As it was it did a great deal of 
damage but it escaped with sufficient remaining energy to penetrate 
8 inches into a tree and 2 feet in the ground where it was found 
undeformed. 

While we were testing the comparative difference between the 
effects of the large and small-caliber bullets in 1893, 2 we shot in the 
skull of a cadaver with the .45-caliber Springfield rifle. The bullet 
weighed 500 grains with an I.V. of 1301 f.s. Fig. 105 has a marked 
resemblance to the preceding. The bullet in this instance entered the 
frontal bone 2. 17 inches above the middle of the right orbit, impressed 
by the simulated velocity at 250 yards. The bone lesion shows that 

1 The Krag-Jorgensen Rifle. A report of its effects on the skull of the living, 
etc., by A. C. Girard, M. C, U. S. A., Jour. Amer. Med. Assn., 1895, No. 25. 

2 Report S. G. O., 1893. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



185 



the explosive effects of the two bullets are quite similar in the proximal 
ranges in the dead or living. The deformed .45-caliber bullet which 
caused the injury is shown in the illustration. 




Fig. 105. — Photograph of skull. (1) Lower orifice marks point of entrance of bullet. (2) 
Upper orifice marks point of exit of bullet. (3) Photo, of bullet left-hand side of figure. No. 
10921 A. M. Museum collection. 

The following is a familiar example of gunshot injury involving 
the frontal lobe: B. C. Barker, Pvt. Co. C, 4th Infantry, was shot 
with a Mauser bullet July 1 at Santiago. The bullet passed through 
the left temporal region, comminuting the bone extensively, and caused 
a wound of exit at the left frontal eminence. Loose fragments 
were removed a few days thereafter when the wound was found to be 
suppurating. When last seen before discharge there was healing of 
wound, no cerebral hernia. Mind was clear most of the time, occa- 
sional confusion and wandering, March 18, 1912. Mr. Barker is now a 
$24 per month pensioner. In a letter written by him March 16, 1912, 



186 



GUNSHOT WOUNDS 



he states that he is entirely incapacitated for work. Lifting, stooping, 
overexertion and heat bring on dizzy spells. 

Makins, referring to the effects of the reduced-caliber bullet, 
found vertical and coronal perforations in the frontal region common 
in the Anglo-Boer War. With lower velocities simple punctured 
fractures in entering and leaving the skull were noted which, as in- 
dicated by the symptoms, were " without extensive lesion of the 
frontal lobes." 




Fig. 106. — A recent photograph of Mr. B. C. Barker, showing the scar and depression of skull over 
the left frontal region. A. M. School collection. 



Stevenson refers to the results in sixty unselected cases of per- 
forating fractures of the skull in the same campaign in which the mor- 
tality was 38.3 per cent. As compared to 80 per cent, in the ninety- 
three cases in the Civil War reported by Otis, the reduction in fatal 
cases is most marked. 

The practice of modern times favors operative interference in 
nearly all cases of gunshot fracture of the skull, and to this practice 
we attribute the greater ratio of recoveries. At the same time that 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



187 




Fig. 107. — Skiagram shows bullet of the .38 cal. Colt's revolver lodged under the skin 2.25 cm. 
above the posterior occipital protuberance. Sgt. V. held the muzzle of the revolver near his head 
and fired with suicidal intent. The bullet entered 5 cm. above bregma near center of frontal bone. 
There was fracture of the cranium along the superior longitudinal sinus from wound of entrance 
to point of lodgment of ball. A fracture extended downward into the left parietal to the middle 
of the left temporal bone. Another fracture extended to the right, to upper part of right temporal 
bone while other fractures were present as shown in skiagrams. Superior longitudinal sinus and 
upper part right cerebral hemisphere badly lacerated. Patient lived but 25 minutes after he was 
shot. The bullet had not sufficient energy to perforate the scalp. Army Med. School collection. 
X-ray Laboratory. Presidio General Hospital. 




Fig. 108. — Skiagram showing side view of Fig. 107. Army Med. School collection. 



188 



GUNSHOT WOUNDS 



lives are saved in larger numbers now, there are sequelae and compli- 
cations among those who survive that are most distressing 

In connection with the subject of perforating wounds by the 
military rifle bullet, it is interesting to note that the same character 
of lesion will occur henceforth from pistol bullets, because automatic 
pistols which fire steel-jacketed projectiles are becoming part of the 
armament of the nations in lieu of revolvers which employ lead bullets. 



r 

i 
| 

i 








- 


^^^ 


i 

^ 




i._ 


, . .... 






•■ 









Fig. 109. — Skiagram showing perforating fracture of head by Colt's new service revolver .45 
cal. lead bullet at close range in cadaver, brain in situ. Ball flattened, lost its penetration and then 
lodged. Note particles of lead in track of bullet. Army Medical School collection. 

Hitherto the greater number of gunshot injuries of the cranium from 
revolvers in both civil and military practice resulted in penetrating 
fractures with lodged balls. This was due to comparatively low 
velocities, and the great tendency of the lead bullets to deform on 
impact against the hard skull. Even in the proximal ranges the bullet 
of the .45 and .38-caliber new service Colts revolvers, two of the most 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



189 



effective weapons of their type, and which were recently discarded 
by our army, failed to perforate the skull in the majority of cases. 
(See Figs. 107, 108, 109.) 




Fig. 110. — Photograph of gun-shot fracture of cranium in cadaver with brain in situ by the 
Luger automatic pistol bullet, cal. 7.65 mm. at 37 1/2 yards, with velocity of 1258 f.s. Bullet 
entered left orbit and emerged above and behind right auditory meatus fracturing left malar, orbital, 
surface superior maxillary, ethmoid, body and great wing of sphenoid, vomer; separated the right 
malar, fracturing frontal over orbit, right parietal, petrous, squamous and mastoid portions of right 
temporal, left parietal and left occipital bones. Philadelphia Polyclinic, service of Dr. A. Hewson. 

Jacketing the bullet of the automatic weapons, and the use of 
smokeless powder, have added to the penetration and velocity of the 



190 GUNSHOT WOUNDS 

new arm to such an extent that its bullets will seldom deform, they 
will lodge less often in the tissues, including the skull. The wounds 
of the cranial region will be of the perforating kind and the lesions 
will more nearly approach those produced by the military rifle. 

Fig. 110 shows the amount of Assuring which results from the 
energy of these powerful pistols. The amount of fragmentation is 
doubtless increased by the fact that the shorter bullet is unstable 
and travels at a tangent to its line of flight on meeting slight resis- 
tance. For ballistics of pistols and revolvers, see pages 72-73. 

Remote Effects of Head Wounds. — The disabling consequences 
of gunshot injuries of the head are very common. Longmore in his 
wide experience states that but few cases of head injuries from gunshot, 
be they contusions or fracture, fail to show evidence of cerebral 
disturbance. 

Cicatrices of the scalp are occasionally painful enough to require 
excision. After either severe injury or concussion to the brain there 
are annoying symptoms such as headache, dizziness, irritability, etc., 
which are noticed in convalescence and more particularly when the 
patient resumes his vocation. In many cases the symptoms persist 
and in some they become worse. Paralytic symptoms are worse at 
first and tend to disappear wholly or in part with time. Symptoms 
like the latter no doubt owe their presence to vibratory disturbances 
and small parenchymatous hemorrhages which tend to disappear with 
the process of repair, and they are at their worst during this time. 
In soldiers they are prone to recur when on duty in hot climates. 
They are aggravated by the use of alcohol. Physical and mental 
endurance are often undertaken with fatigue; patients are disturbed 
by trifles and sensitive to sensory stimuli. The memory may be 
impaired; patients forget names, they become forgetful through 
lack of attention. Changes in character may be seen; those who were 
formerly of a cheerful disposition become eccentric, irascible, moody, 
and fault-finding. Epilepsy is common, and insanity has been noted. 
Destruction of specialized areas of the cortex like the speech center is 
apt to remain permanent. 

The complications of gunshot fracture of the skull are concussion, 
compression and hemorrhage, with meningitis, encephalitis, hernia 
cerebri and brain abscess as sequelae. 

Concussion, Compression and Hemorrhage. — The symptoms of 
concussion and compression are difficult to differentiate in the begin- 
ning unless depressed bone is apparent. They are usually accom- 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 191 

panied by unconsciousness and shock. It should be remembered 
that concussion per se is rare in gunshot of the skull, while compres- 
sion from depressed bone or hemorrhage either above or below the 
dura is common. Concussion which results from contusion, guttering 
or the minor injuries to the skull is apt to be transient. In penetrating 
or perforating wounds, the symptoms of brain injury accompany those 
of compression if the latter be present. The symptoms of compres- 
sion from depressed bone occur immediately after the receipt of the 
injury, while the symptoms from hemorrhage are more apt to come 
gradually. Hemorrhage between the skull and dura may be produced 
by contusion or fracture. The middle meningeal or some of its 
branches are usually implicated especially if the bleeding is severe. 

Meningitis, encephalitis, hernia cerebri and brain abscess are 
grave symptoms because nearly all fatal cases of gunshot injury of the 
head in the later stages die from one or more of these complications. 
It is needless to state that they all arise from primary infection which 
is prone to occur in head wounds. 

Hernia cerebri is one of the common and very fatal complications 
of gunshot fracture of the cranium. It results from rupture of the 
dura in fractures of the skull by the penetration of missiles or de- 
pressed fragments of bone. It may be primary or secondary. In 
the primary form there is usually a larger opening through which the 
brain matter escapes beyond its normal level, at the time of the injury. 
It is most generally the result of pressure exerted by internal hemor- 
rhage. In recent wars it has been noted as an accompaniment of 
cranial fracture attended with explosive effects from proximal shots 
by the military rifle. The secondary form results from intracranial 
pressure which may be exerted by an abscess or by the products of 
inflammation as in meningitis and encephalitis. Primary cerebral 
hernia is nearly always fatal. Otis reports fifty-five cases of secondary 
cerebral hernia with a mortality of 80 per cent. Stevenson refers to 
twelve cases in the Anglo-Boer War with a mortality of 41.9 per cent. 
In the Russo-Japanese War Lynch reports upon the frequency and 
fatality of cerebral hernias in the Japanese hospitals. He attributes 
their frequency to the large openings made in the skulls by the 
Russian surgeons. The protruded mass is usually covered by granu- 
lating tissue. 

Treatment of cerebral hernia consists in protecting the ulcerated 
surface by clean dry dressings applied with moderate pressure. The 
parts should be washed daily with mild antiseptic solutions and gently 



192 GUNSHOT WOUNDS 

dried before reapplication of the dressing. Absolute alcohol is 
recommended, to be painted on the growth daily for its cleansing and 
dehydrating effects. Excision and cauterization have their dangers 
but they have been attended with success. Skin transplanting and 
osteoplastic repair have given good results in suitable cases. Gangrene 
and spontaneous separation sometimes result in cure. The stump is 
covered by granulations and finally healed by connective-tissue 
formation. 

Abscess of the brain as a complication of gunshot fracture of the 
cranium rarely appears earlier than the tenth day, but more often 
during the second and third weeks. The symptoms are nearly always 
insidious in their onset. They consist of slight rise of temperature, 
headache, chill, nausea and vomiting, drowsiness. Jacksonian 
epilepsy appears in some cases, also irritability of temper. Choked 
disk is fairly constant, and slow pulse is a significant symptom. 

When abscess is suspected exploration with a hypodermic needle 
or small trocar should be practised at once, and when pus is found it 
should be evacuated, and the abscess cavity irrigated and drained. 
The abscess will usually be found in the injured area but not necessarily 
so. In any event it should be sought for in the area indicated by the 
localizing symptoms. 

Treatment of gunshot fractures of the cranium consists in prompt 
operative interference in every case that offers any hope of recovery. 
With our present knowledge we know that the expectant attitude 
employed in the days of our Civil War was responsible for a large 
number of deaths. It was in order then to await symptoms and 
then to operate. If we pursued the same practice to-day our results 
would be but little better notwithstanding the aid which we receive 
from antiseptic treatment. A gunshot fracture of the cranium is in 
the nature of a punctured wound and it is infected primarily by the 
ball and skin of the scalp in every case. Cases in which the ball has 
traversed the brain deeply near the base, and those cases exhibiting 
long bullet tracks vertically or transversely except in the frontal lobes 
give but little promise of relief by operation. The same is true of 
gunshot in any region which bears evidence of explosive effects from 
proximal shots. In the latter, the brain and bone lesions are marked 
by fissures, lacerations, and brain pulp is present beyond the bullet's 
track. Spicula of bone and often particles of metal are driven into 
the brain substance, causing dangerous wounds in themselves. 

The time for operation should be immediately after the receipt of 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 193 

the injury, because delay means sepsis. Of the cases demanding 
attention at a dressing station, the head cases should be among the first 
selected. Since infection is about the only danger to be feared, the 
greatest precaution should be taken to prevent infection from the 
beginning. To that end the scalp should first be shaved and cleansed. 
In the emergent conditions attending battle there is scarcity of water, 
as a rule. Fortunately tincture of iodine or LugoPs solution is a ready 
and efficient substitute in the field, and one or the other of these should 
be applied in 50 per cent, strength to the whole scalp as soon as it has 
been shaved or closely clipped. A flap should next be raised at the 
wound of entrance with its convexity directed in the best way to 
promote drainage, the bullet opening forming the center of the raised 
flap. If the opening in the skull is not sufficiently large to permit 
thorough exploration space can be gained by the use of the rongeur. 
Loose fragments under the scalp and those driven in and about the 
entrance wound should be sought for and removed. It is well to 
explore the channel in the brain for 2 inches or more for lodged pieces 
of bone, the bullet, or pieces thereof. All fragments and foreign bodies 
having been removed, the disintegrated brain pulp and blood clots are 
carefully washed away. The scalp wound is then closed by suture 
without drainage. The latter can be secured most readily at any 
subsequent time if necessary. The surgeons in recent campaigns 
insist upon the value of primary union, an outcome which so readily 
insures against the occurrence of complications of a fatal or annoying 
nature. The wound of exit, if it shows marked lesion, should be treated 
likewise. The less severe cases seldom require more than cleaning and 
a primary dressing. Gutter fractures wherein the floor of the gutter is 
formed by the fragmented inner table should be freed of fragments 
and the edges of the two tables made smooth by rongeur-f orceps. De- 
pressed fractures without perforation should be explored and the de- 
pressed fragments replaced. Fragments of the inner table which cause 
pressure on the dura or brain should be removed entirely. It is a safe 
rule to explore all gunshot wounds of the cranium whether fracture is 
apparent or not. In cases of doubt no harm can come from removing 
a half-inch crown of skull near the point of impact, for the purpose of 
exploration. Such a practice is prompted by the number of cases 
which are related in all works on military surgery of apparently trivial 
contusions, which later terminated disastrously from injury to the 
brain or its membranes. In this connection we should remember that 
gunshot wounds differ from wounds by other offending bodies, in that 

13 



194 GUNSHOT WOUNDS 

the missile is usually animated by an amount of energy which is 
often dissipated in the production of fractures which are not always 
apparent to the sense of touch or sight. 

The treatment above indicated was faithfully followed by the 
British surgeons in the Anglo-Boer War. The army was accompanied 
by celebrated clinicians who carried out the policy of early, thorough 
and careful exploratory work in all head cases. The consequence was 
that their average mortality in sixty-three gutter, thirteen penetrat- 
ing and sixty perforating fractures of the cranium was only 29.1 per 
cent. The boldness and forethought of the British surgeons is well 
worthy of emulation. No doubt their example will be a factor in the 
reduction of the fataluy of head wounds in the wars of the future. 
The same plan of treatment was observed in the Manchurian campaign, 
according to Dr. von Oettingen. 1 The value of early operation to 
ward off abscess, meningitis, etc., was clearly demonstrated. He in- 
troduced his finger covered with a rubber glove deep into the wounds 
to cleanse them of all bone and metallic fragments. 

The management of cranial injuries by military surgeons in the 
present European war has served to emphasize the rules of treatment 
referred to above, and with the exception of the excellent article by 
Gordon Holmes and Percy Sargent in the British Medical Journal of 
October 2, 1915, on Injuries of the Superior Longitudinal Sinus there 
is nothing new on the management of head cases in active campaign. 
Lesions of the longitudinal sinus are rarely seen in civil practice. 
Here the vascular lesions of the brain point to arterial disease, while 
primarily affections of the cerebral veins are uncommon. 

In gunshot fractures, especially tangential shots, disturbance of 
the cerebral venous circulation is frequent, owing to the superficial 
course of the cerebral veins. The thinner walls and the lower pressure 
of the blood that flows through them make them more liable to be 
blocked by slight pressure than the arteries. Striking clinical effects 
are produced when the cranial sinuses, into which these veins flow, are 
affected and naturally the most common sinus to be involved is the 
superior longitudinal sinus. The striking difference in the palsies 
noted was the rigidity in the limbs and the distribution of the paralysis 
and its relative severity in different segments. When the upper limb 
is affected the finger movements escape or are only involved for a 
short time after the injury and rapidly recover to regain their normal 
power. The hand movements do not remain weak long, except when 
1 Munch. Med. Wochens., 1906, No. 7, p. 218. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 195 

the sinus lesion is complicated by an independent injury of the brain. 
The wrist and elbow movements are affected more severely and re- 
cover less rapidly, and the same is true of the shoulder movements. 
This is the reverse of what occurs in ordinary hemiplegia. The dis- 
tribution of the palsy in the legs is the converse of that in the arms, 
in all cases of sinus lesion. 

The rigidity is more striking than the unusual distribution of the 
paralysis; it is co-extensive with it and closely related to it in a degree. 
It is a very early symptom, appearing within 24 hours of the receipt 
of the injury. 

When operation is necessary it is advisable to remove bone all 
around the depressed area, and only then elevate this, for if hemor- 
rhage occurs the surgeon is then in a more favorable position to control 
it. Bleeding from the sinus or its lacunae occurs when the fragments 
of bone are removed, but it may generally be arrested by pressure with 
a piece of pericranial tissue, keeping it in position for a short time ; 
this is used in preference to a gauze plug which is only recommended 
when the sinus is completely divided or much lacerated. Experience 
has shown that immediate operative interference is unsatisfactory. 
Of 39 cases observed which were operated upon, 15 died; only one died 
out of 37 cases not operated upon before transference to England. 
The latter group were, however, lighter cases. Uncomplicated cases 
show a remarkable tendency to improve, a fact due, no doubt, to the 
free venous anastomosis permitting a re-establishment of the circulation. 

The majority of surgeons favor early operation in all head wounds, 
as already stated. The chances of good recovery without subsequent 
complications incident to infection will be very much better when the 
patient happens to fall into the hands of cranial specialists who may 
be provided with the necessary equipment for diagnosis and treatment. 
These are difficult of attainment at the front. In the absence of com- 
petent help and adequate resources Cushing 1 believes that, with the 
exception of the more serious wounds with much hemorrhage, cranio- 
cerebral injuries as a rule present no immediate urgency for operation. 
He claims that the brain tissue is notably tolerant of contusions and 
infections and that a delay of three or four days in rushing this class of 
wounded to a suitable base is preferable to the delay of two or three 
days in having them recover from the effects of an incomplete proce- 
dure before transportation. 

1 Concerning Operations for Cranio-cerebral Wounds of Modern Warfare, 
Military Surgeon, July 1916, by Harvey Cushing, M. D. 



196 GUNSHOT WOUNDS 

Cushing, like other surgeons, is a firm believer in early operation in 
almost all projectile wounds, even though they appear trivial. The 
exceptions to this rule are the longitudinal sinus injuries mentioned by 
Holmes and Sargent, and also certain fractures at the base due to per- 
forating wounds, because they are inaccessible. 

The plan of administering one or two drachms per day of urotropin 
to prevent or cut short intra-cranial sepsis, first advocated by Cushing 
is employed by many of the military surgeons in the present World 
War. The amount of the drug, or of its products of decomposition, 
which washes the cerebro-spinal fluid must be very small. 

Operations upon Gunshot Wounds of the Head. — In the present 
War the surgeons have been impressed more than ever with the value 
of prompt operative interference to prevent sepsis: (1) to remove septic 
matter when the dura is injured or uninjured; (2) to remove depressed 
fragments of bone; (3) to control hemorrhage; (4) to operate very 
promptly for the relief of intra-cranial pressure. 

(1) Operation to Remove Septic Matter when the Dura is Un- 
injured. — The practice is now to carefully excise the scalp wound 
after the scalp has been shaved and thoroughly cleaned with ether and 
tincture of iodine, or some equally satisfactory skin disinfectant. The 
wound is excised with a sharp knife through sound tissue beyond the 
injured margin down to and to include the pericranium. This is 
done under local anaesthesia like the mixture of novocain and adren- 
alin. In large wounds it may become necessary to loosen the scalp 
by sweeps of the knife next to the skull to obtain approximation. 

Excision of the wound as recommended enables thorough examina- 
tion of the underlying bone. In the event of fragmentation the sur- 
geon proceeds to correct the injury in the methods prescribed. The 
dura being uninjured the scalp wound is now sutured. 

In cases in which the dura has been injured by depressed frag- 
ments, one has to consider the steps to be taken at an early and a 
later stage. 

In early cases, within a few hours after injury, the infection is 
superficial, in glancing shots especially. After excision of the scalp 
wound as already recommended, the wound may be enlarged, if neces- 
sary, and by retracting the edges there will be enough room for a simple 
trephining operation and the necessary attention to depressed bone 
and the removal of loose fragments and foreign bodies. When drainage 
is unnecessary the wound may now be sutured in the form of a simple 
linear wound. In larger wounds it becomes necessary to employ a 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 197 

flap incision which gives the surgeon more room to work. The 
surgeon now proceeds in the usual way to remove the injured tissues, 
and when it is possible to do so, the infected bone should be removed 
in the same way that excision in soft parts was recommended, viz.; 
excision of damaged bone en masse. This is accomplished by making 
a trephine opening to one side of the fracture and then making an 
incision with bone forceps around the damaged bone. The fractured 
and septic tissue can thus be taken away without spreading the in- 
fection. After the wound has been thoroughly explored to remove 
all loose fragments, the track of the wound should be explored with 
the finger for loose fragments in the brain tissue. The operation 
should be conducted under a stream of saline solution. The scalp 
wound is next sutured without drainage. Some surgeons employ 
drainage tubes at the lower angles of the flaps. 

(2) Operation for the Removal of Depressed Fragments at a Later 
Stage. — In later cases sepsis has extended into the tissues, there is 
more or less intra-cranial pressure and adhesions have formed between 
the meninges. 

In these cases the operation is carried on in the same way as in 
the early stage. It is however essential that the protective adhesions 
between the pia, arachnoid and dura be conserved, and in so doing, 
one should remove fragments through the injured aperture in the dura. 
When intra-cranial pressure is raised and the dura is pulseless, spinal 
puncture is employed and two or three drachms of fluid allowed to 
run off. When necessary the puncture may be repeated. When 
intra-cranial pressure continues operation for its relief is in order. 

(3) To Control Hemorrhage. — Hull 1 recommends the use of infil- 
tration anaesthesia, by a solution of J^ per cent, novocain to which is 
added sulphate of potassium ninety grains, and a drachm of ad- 
renalin solution to eight ounces. A general anaesthetic is rarely 
necessary. 

Hemorrhage from bone is controlled by pressing a piece of muscle, 
cut from the wound, against the bleeding bone or by pressing sterilized 
bees-wax against the bleeding surface. 

(4) Operations for the Relief of Intra-cranial Pressure. — Decom- 
pression is practised during an operation for the removal of depressed 
fragment, or a foreign body, or when one is operating for meningeal 
or subdural hemorrhage. For the lesions incident to projectile injuries 
the operation does not differ from that for other traumata, which 
may be found in text books on surgery. 

1 Op. cit. 



N. 



198 GUNSHOT WOUNDS 

Removal of Lodged Missiles. — Attempts to remove foreign bodies 
like bullets or pieces of shell from the brain are to be discouraged 
unless the indications are prompted by easy access, as shown by the 
Rontgen-ray plate, or by very annoying symptoms. Past experience 
discourages the practice of prolonged search for balls, which more 
often ends in failure and the infliction of wounds more dangerous than 
the presence of the foreign body itself. The inconveniences of a ball 
buried in the brain are not sufficient to warrant the risks of operation, 
as a rule. Fortunately, lodged missiles from the present armament 
will rarely occur because of the superior penetration of the jacketed 
bullets. Furthermore, the reduction in weight of military rifle bul- 
lets from 500 to 150 grains will be attended with fewer and less severe 
symptoms from lodged missiles in the brain than have been noted 
heretofore. 

(2) Gunshot Wounds of the Face. — Gunshot wounds of the face 
have their chief interest 4n the disfigurement which follows injuries 
by shell fragments and large-caliber rifle bullets. The mortality of 
face wounds has never been high. Secondary hemorrhage and sup- 
puration, extending to the meninges from necrosis of bone and lodged 
balls embedded in the spongy bones of the nasal and supramaxillary 
regions, were the chief causes of death in preantiseptic times. Among 
2276 gunshot injuries entered on the U. S. Army registers for 1899 
from all kinds of missiles there were twenty-seven fractures of the bones 
of the face with two deaths. 

The character of wounds from shell fragments, shrapnel and 
large-caliber rifle bullets is the same to-day as formerly and in spite 
of our best endeavor deaths still occur from inflammation extending 
to the meninges and brain. The absence of disfigurement from shots 
by the modern military rifle bullet, beyond the proximal ranges, is one 
of the striking evidences of the beneficence which comes from the 
use of a new arm. 

Wounds of the Ear. — Wounds through the pinna are slit-like and 
heal rapidly. Shots in and near the external auditory meatus are 
apt to end in paralysis of the seventh nerve and deafness as a result 
of vibratory concussion. 

Wounds of the Orbit. — These are common and serious to vision. 
Transverse shots are the most serious as they are prone to injure both 
eyes. Aside from direct traumatism to the globe or optic nerve itself, 
blindness has frequently been observed in recent wars from vibratory 
impulses on impact, causing minute hemorrhages from rupture of 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



199 



choroidal vessels. In such cases unless vision returns soon after 
the receipt of the injury the prognosis is bad. In the case of an 
officer who received a transverse shot from a Mauser bullet at 
Santiago just beneath the orbits, it is at present impossible to de- 
tect, on careful inspection, the scars which mark the location of 
the wounds of entrance and exit. The author had this officer for a 
patient a few days after he was wounded, and he has served with him 
for two years since, on his official 
staff, but he cannot recall any 
visible disfigurement from the 
effects of the wounds. The left 
eye was injured at the time, caus- 
ing total blindness, so that it was 
subsequently enucleated, and the 
vision in the right eye remains 
slightly impaired as a result of 
vibratory concussion. 

Fig. Ill shows the dangers of 
the .22-caliber target practice am- 
munition so much used in this 
country for sporting purposes, and 
also used in our army for gallery 
practice. Private Frank Piaski, 
Co. H, 30th Infantry, was shot 
while in target pit March 28, 1910, 
with a .22-caliber (short commer- 
cial) cartridge, the bullet entering 
the right eye just above the inner 
canthus, resulting in total blind- 
ness in the injured eye. As seen 
in the figure the ball lies lodged 
in the back part of the orbit and 

its path is marked by a stream of lead particles. The latter would 
indicate that the ball was deformed on being deflected by the frontal 
bone at the lower and internal end of the superciliary ridge where 
the bone is thick, and, having lost its momentum, it lodged as shown 
in the skiagram. 

Wounds of the Nose. — The cartilages of the nose like those of the 
pinna of the ear suffer slit-like wounds that heal readily. In the case 
of an officer at the battle of Santiago, whose case has already been 




Fig. 111. — Skiagram shows .22 cal. bullet 
lodged in orbit. Army Med. School collection. 
From Letterman Genl. Hospital. 



200 



GUNSHOT WOUNDS 



referred to under the subject of multiple wounds, the ball perforated 
the soft parts of the cheek, then passed through the cartilages of the 
nose in and out in a transverse direction. The wounds were trifling 
in their nature and he preferred to return to the line rather than suffer 
shipment home with other wounded. Wounds of the nasal fossae 
have been known to destroy the sense of smell, most likely as a result 
of vibratory impulse. 

Wounds of the Malar Bones. — The malar bones are the most 
resistant bones of the upper part of the face and shots received in the 
explosive zone are apt to be attended with Assuring and displacement 
of bone fragments, causing lacerations which in turn augment the 
tendency to inflammation. In the mid and remote ranges the bone 
lesion takes the nature of a perforation. 





\i 



Fig. 112 Fig. 113 

Fig. 112. — Radiograph of G. W. G., showing lead slug lodged in base of tongue. The ball 
entered behind the left ear. Radiograph taken fourteen months after injury. Remote effects: 
Left hemiparalysis of tongue,also loss of taste on left side; loss of hearing in left ear; left optic neuritis; 
partial anchylosis of lower jaw and painful deglutition. The bullet was removed Oct. 4, 1900. The 
painful deglutition was completely relieved. Photo of bullet is shown in Fig. 113. Army Med. 
School collection. U. S. Soldiers Home X-ray Laboratory. Dr. A. B. Herrick, X-rayist. 

Wounds of the Upper Jaw. — These are apt to include the antrum, 
buccal cavity, alveolar process and teeth. The latter are often 
displaced with violence, causing lacerations which are painful and 
heal slowly. Lt. W. S. W., 9th Cavalry, was shot by a Mauser bullet 
at Santiago July 1. The bullet entered the lower lip near the right 
angle of the mouth, causing loss of four teeth in the lower jaw and 
fracture of the four upper incisors and right upper molar. It was here 
deflected and passed under the inferior maxilla and lodged in the 
left sterno-cleido-mastoid. There were lacerations in the mouth 
and tongue causing much pain and discomfort with attendant in- 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



201 



flammation which extended down the neck. The bullet was removed 
from the substance of the sterno-cleido-mastoid about its middle, at 
Soldiers Home Hospital, D. C, in October, 1898. 




Fig. 114. — Pvt. Cornelius L. E., Co. " K," 1st Neb. Vol. shot in face by a .45 cal. brass-jacketed 
Remington bullet Feb. 5, 1899 at Block-house No. 7 P. I. Bullet entered over left eye-brow 1/2 
inch from inner canthus and lodged in right antrum of Highmore. Removed by Maj. A. C. Girard, 
M. C, U. S. A., at Letterman Genl. Hospital, Aug. 16, 1899. Remote effects: Partial deafness 
left ear; total blindness right eye from choroiditis and optic atrophy; anchylosis of jaw, but slight 
separation of teeth. Letterman Hospital X-ray Laboratory. 

Balls penetrating the buccal cavity often groove or perforate the 
tongue, but they seldom lodge in its substance. Figs. 112 and 113 
show an improvised Filipino bullet from a Mauser rifle which we re- 



202 



GUNSHOT WOUNDS 



"s 



moved from the base of the tongue and Fig. 114 shows a jacketed bullet 
lodged in the antrum. 

Wounds of the Lower Jaw. — When the mandible is struck by a 
high-velocity bullet, its compact substance splinters readily, causing 
corresponding damage to soft parts. The traumatism is greater 
still when teeth are displaced from the alveolar process. In the 
mid and remote ranges the small jacketed bullet is apt to gutter or 




Fig. 115. — This soldier shot himself at Jolo, P. I., in 1907, with Springfield rifle cal. .30 more by 
accident than intent. While in the company of several of his comrades one evening, he desired them 
to believe that he was about to commit suicide and placed the muzzle of his weapon under his chin 
saying, "here goes boys," at the same time pulling the trigger. He admitted afterward that he 
intended to throw his head back far enough to avoid the ball, but failed to do so, receiving a wound 
which shattered the inferior maxillary bone and lacerated the surrounding tissues. The case illus- 
trates how much disfigurement can occur from reduced caliber rifle bullets at proximal ranges. 
Army Medical School collection. 

perforate the bone with little splintering. Fractures of the upper 
part of the ascending ramus and neck of the condyle are often at- 
tended with comminution and are apt to cause anchylosis unless 
properly explored at the time. 

Treatment. — In wounds of the orbit with brain injury, if the bullet 
has passed from the orbit to the brain, it is preferable to enucleate the 
eye at once and remove such spicula of bone as may be necessary 
from the wound of entrance in the roof of the orbit. In all other 
cases with concurrent brain injury in which the globe has been de- 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 



203 



stroyed it is preferable to defer enucleation until after closure of the 
wound in the orbital roof. In cases of lodged balls in and about the 
orbit the missile should be removed at once and enucleation practised 
at the time if necessary. Fracture of the upper jaw seldom needs 
active treatment except to remove spicula of bone, teeth, and lodged 
missiles when localized by the X-ray or otherwise. In the case of 
the mandible when the buccal cavity is involved, prompt active 
treatment is necessary to remove all pieces of loose bone which may 
favor suppuration and necrosis later. Prompt removal of com- 
minuted bone should also be practised in fractures of the ramus to 
forestall anchylosis of the lower jaw, which is so apt to occur with the 
extensive comminution and resulting callus. Fixation should be 
practised by a four-tailed chin bandage which is about all that is 
obtainable in the field. Later the more permanent and effective 
methods of fixation should be employed. Wounds of the lips, cheeks, 
and tongue usually heal rapidly. Antiseptic mouth washes should 
be employed in wounds implicating the tongue, buccal and nasal 
cavities. 

(3) Gunshot Wounds of the Neck. — Shot wounds of the neck, 
exclusive of injury to cervical vertebrae are not excessively fatal. Of 
4114 known results of this class of cases reported in the surgical vol- 
umes of the Civil War, Otis gives a mortality of 15 per cent. The 
sub-joined table from the same source, aside from giving the mortality 
for that time, is interesting as it gives the ratio of hits in some of the 
important anatomical structures for a large number of neck wounds. 



TABLE OF 4895 CASES OF GUNSHOT WOUNDS OF THE NECK WITHOUT KNOWN 
INJURY TO THE CERVICAL VERTEBRAE (OTIS) 



Character of wound 


Cases 


Died 


Dis- 
charged 


Duty 


Un- 
known 


Gunshot Wounds of the Neck, injuring Larynx 


4789 

41 

30 

13 

10 

4 

2 

2 

1 

1 

2 


570 

21 

10 

7 

6 

2 


1056 
11 
8 
2 
2 
1 
2 


2394 
8 
2 
3 
2 
3 


769 

1 

10 


Gunshot Wounds of the Neck, injuring Tra. & Phar 


1 


Gunshot Wounds of the Neck, injuring Tra. & Esoph 

Gunshot Wounds of the Neck, injuring Lar. & Esoph 

Gunshot Wounds of the Neck, injuring Phar. & Esoph. . . . 
Gunshot Wounds of the Neck, injuring Phar. & Lary 






1 






1 




2 














Aggregates 


4895 


618 


1083 


2413 


781 



204 GUNSHOT WOUNDS 

The high mortality in those wounds involving the trachea, larynx, 
pharynx and esophagus alone or otherwise is no doubt significant of 
the effects of the armament and mode of treatment at that time. 
The large number of cases, viz., 4789 of gunshot wounds of the neck, 
with an aggregate mortality of 14.1, shows even for the old armament 
how curiously the large vessels and spinal cord escape injury in this 
rather limited target area. A line drawn transversely at the root of 
the average size neck in life measures about 4 1/2 inches, and 4 inches 
when the measurement is taken transversely arcoss the neck under 
the extended chin. The antero-posterior and oblique diameters at 
about the same levels exceed these measurements by about 1/2 inch. 
In the middle of this space the spinal column runs longitudinally 
and it measures on the skeleton approximately an average of 2 inches 
transversely, while the spinal canal proper measures about 3/4 inch 
in its antero-posterior diameter. 

The failure to note vertebral lesions in this array of neck wounds 
is due no doubt to their entire absence. Such cases were very probably 
numbered among the dead from direct injury to the cord or as a result 
of vibratory concussion in bone injuries so near the vital centers. 
The record makes note of primary and secondary hemorrhage in a 
certain proportion of cases, but the principal feature of the neck wound 
for that day was the striking manner in which the missiles, like round 
and conoidal lead balls, eluded the great vessels while from every 
external appearance they traversed their course. It was then believed, 
and very properly, that the vessels lying loose and movable in the 
tissues were pushed aside by the slowly moving obtuse bodies. In 
those cases where the vessels were severed, the larger caliber of those 
days caused so much laceration of the large vessels that the result was 
immediate death from primary hemorrhage. 

The beneficence which comes from reduction in the caliber of the 
military rifle is very evident from the results in neck wounds in recent 
wars. This was noticeable to us at Santiago in cases of injury to the 
air passages and the great vessels alike. The larynx, trachea, and 
great vessels were all in turn perforated without fatal outcome. The 
death rate of 133 neck cases who lived to reach hospital care in the 
Spanish- American War was 18 per cent. Two of the fatal cases 
were operated upon for subclavian aneurysm. Although the offi- 
cial reports from the Anglo-Boer and Russo-Japanese Wars are not 
yet available, we have reason to believe from the published reports 
of the observers in these wars that the results in the Spanish- American 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 205 

War are a fair index of the mortality to be expected from shot wounds 
of the neck under present conditions. 

We noticed a number of cases, after the battle of Santiago, of 
incredible escape of important structures in the neck and our 
observations have been confirmed repeatedly by observers in recent 
wars. 

In the case of Pvt. 0. C. Buck, Co. F, 2d Infantry, who was 
shot by a sharp-shooter July 11, a Spanish Mauser bullet passed 
transversely through the neck. Profuse bleeding from the throat 
followed immediately, but this soon subsided and ceased entirely 
during the day. No other symptoms were present in the subsequent 
history of the case except slight stiffness of the neck and pain on 
movement. The bullet entered on the left side 2 inches below the 
mastoid process, making a small circular wound, and passed through 
the sterno-cleido-mastoid muscle; the wound of exit was on the oppo- 
site side of the neck, on the same level and 1/2 inch nearer the spine. 
There were no subsequent symptoms of a nature referable to the 
principal nerves and large vessels of the neck, and yet it is difficult 
to conceive how the projectile made its passage through the neck 
without involving these important structures. 

The spinal column and cord made a marvelous escape in the case 
of Pvt. Charles F. F., Company C, 4th Infantry, who was wounded 
July 1, while firing in the prone position. The bullet, a Spanish 
Mauser, entered the left side of the neck opposite the fifth cervical 
spine mid-way between it and the posterior border of the sterno- 
cleido-mastoid. Ranging downward and to the right it made its 
exit opposite the seventh dorsal spine half-way between it and the 
vertebral border of the scapula. The only symptom complained of 
was pain in the shoulders on moving the arms. No symptoms of a 
paralytic or other nature referable to cord lesion were ever present, 
although he was shot when 100 yards from the enemy. 

Makins mentions the occurrence of " several cases in which the 
bullet traversed the neck behind the pharynx and esophagus without 
injury to either viscus, and the escape of the main vessels and nerves 
was equally striking. " Follenfant in Manchuria states that his com- 
rade, Prince Murat, received a wound across the neck which disabled 
him very much for six days. He was back on the line at the end of 
a few weeks. The jacketed bullet entered the right side of the neck 
under the angle of the lower jaw and emerged on the left side behind 
the larynx. There was difficulty in deglutition for five days. No 



206 GUNSHOT WOUNDS 

after-effects were present save an anesthetic patch the size of a 5-franc 
piece on the right side of the neck. 

Complications of Gunshot Wounds of the Neck. — Wounds of the 
larynx and trachea are sometimes complicated with septic pneumonia ; 
injury to the great vessels may cause hemorrhage or traumatic 
aneurysm, while wounds of the esophagus are prone to infection. 
Infection in any wound of the neck, unless carefully managed, is apt 
to lead to deep-seated inflammation with suppuration. 

Wounds of the Great Vessels or Their Branches. — Aneurysm 
which arises from wounds of neck vessels will be referred to under 
11 Injury of Blood-vessels." 

Hemorrhage attending laceration of vessels of the neck when 
alarming and continuous should be treated by ligation of the vessel 
a*bove and below the point of injury. In large wounds as by shell 
fragments or large lead bullets, patients seldom live long enough 
to reach surgical aid. Smaller missiles like the steel-clad bullets of the 
present-day military rifle often cause wounds in which the flow of 
blood is not constant, due to the small channel made by the pro- 
jectile, and to obstruction of the flow which results from a change 
in the position of the overlying layers of muscle, fascia, etc. A re- 
currence of the hemorrhage after a temporary spurt of blood should 
be an indication for cutting down upon the bleeding vessel. The 
sooner this is done, the better will be the prognosis. Temporizing in 
such cases leads to the disturbances of anatomical relations from the 
distention which attends the formation of diffuse aneurysm. In 
our Civil War the surgeons were wont to use pressure and styptics. 
Again, instead of cutting down upon the vessels at the point of injury 
they often resorted to the faulty practice of tying the common carotid 
to control hemorrhage from some of its branches. Otis' characteri- 
zation of this method is as applicable to-day as it was then. To him 
these surgeons were only " associating their names with the necrology 
of ligations." He makes note of a total of seventy-six ligations of 
the common carotid for gunshot about the face and neck with a mor- 
tality of 78.6 per cent. This practice was not attended with very 
much better results in the Franco-Prussian War of 1870-71, where the 
registered mortality in like cases was 68.7 in the German Army. 
The surgical practice of to-day is to cut down and tie the bleeding 
points in the wound wherever this is possible. When, however, the 
wound in the neck is above the bifurcation of the common carotid, 
in the parotid region, there is usually much difficulty in attempting 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 207 

to expose the bleeding vessel. It is then difficult to ascertain which 
of the divisions of the main trunk is causing the hemorrhage. In 
such a case operators follow the practice first recommended by Richet 
of exposing the origin of the two carotids, then successively to compress 
the vessels and finally to tie the one that seems to control the hemor- 
rhage. If the compression of the one or the other does not entirely 
arrest the hemorrhage, he then advises ligation of both the external 
and internal carotids. As an additional precautionary measure to 
prevent a recurrence of the hemorrhage, Delorme 1 would enlarge the 
skin incision and pack the wound with antiseptic tampons. Follen- 
fant 2 states that Bornhaupt, contrary to the usual practice, tied the 
common carotid twice successfully for hemorrhage in the late Russo- 
Japanese War. 

Wounds of the Jugular Veins. — Wounds of the external jugular 
are of no moment in our day, though Otis records some cases of death 
from gunshot of this vessel in our great Civil War. Ligation of both 
ends of the vessel under proper antiseptic precautions is the treatment 
now employed. Wounds of the internal jugular have a high mor- 
tality. Large veins are not as resistant as the large arteries, they are 
not pushed aside as readily by slowly moving projectiles and it is more 
than likely that the mortality on the field from primary hemorrhage 
is frequent from uncontrollable venous hemorrhage. Otis records 
fifteen cases of wounds to the internal jugular with fourteen deaths. 
Eight of the deaths are ascribed to hemorrhage, five not stated, and 
one from typhoid pneumonia. Of the cases of gunshot wound of the 
internal jugular collected by Gross the fatality was 12.5 per cent, 
from primary hemorrhage; 62.5 per cent, from secondary hemorrhage; 
25 per cent, from pyemia. These statistics are of much value since 
they point to causes of death in 87.5 per cent, of the cases, which 
under modern methods of treatment are largely preventable. Doubt- 
less the mortality of 12.5 per cent, from primary hemorrhage could 
be much reduced by ligation of the vein, which is now done with 
perfect safety. Injury to the jugulars and other large veins by the 
modern rifle bullet, which are accessible to operative interference 
when seen in time, will be especially amenable to surgical relief in 
the majority of cases. Where the vein has been hit at a tangent, 
application of fine sutures to the margins of the wound in the vessel 
is one of the recognized procedures. If the wound is very small it 

1 Delorme E., Traite de Chirurgie de Guerre. 

2 Op. cit. 



208 GUNSHOT WOUNDS 

can be brought together by a hemostat which can be left in situ for 
a few days. Where the vessel has been perforated by the projectile, 
destroying the greater part of its lumen, the procedure is the same as 
that followed in the case of an injured artery, viz., ligation of the vessel 
above and below the point of injury. 

Wounds of the Nerves of the Neck. — All the nerves of the neck 
including the sympathetic are subject to injury by gunshot. Unlike 
injury to nerves of other regions there is little that can be done in 
the way of surgical relief for nerve injuries in this locality. 

The German reports for the war of 1870-71 place the frequency 
of nerve injuries as 1 to 12 of all neck wounds by gunshots. These 
injuries are often followed by interesting clinical signs. Injury to the 
seventh nerve, which often occurs in wounds about the parotid, is 
invariably followed by complete or partial facial paralysis. Wound of 
the recurrent laryngeal will cause paralysis of the muscles of phonation 
on the corresponding side with difficulty in speech; lesion of the 
spinal accessory, paralysis of the mastoid and trapezius muscles; of 
the phrenic, paralysis of the diaphragm on the corresponding side, 
with hiccough, dyspnea and a sensation of constriction around the 
body. Of the foregoing injuries wounds of the phrenic are the most 
serious. 

Wounds of the pneumogastric by gunshot are attended with 
an interesting and curious clinical history. By reason of the nerve's 
intimate relation to the large vessels the latter are nearly always im- 
plicated, but in some rare instances the nerve alone has been injured, 
and the symptoms of injury to it have also been noted where the 
primary hemorrhage of the vessels has been successfully arrested. 
The pneumogastric is often implicated in neck injuries, (a) by direct 
traumatism, (b) by pressure in cases of aneurysm and (c) by the vibra- 
tory force of high-power military rifles of the present day. Injury to 
this important nerve is followed by difficulties of deglutition, phonation 
and respiration; irregularity and acceleration of the heart beats, and 
later by pneumonia which is sometimes a cause of death. Makins 
states that the pneumogastric was often implicated in gunshot wounds 
of the neck in the South African War. He never observed an uncom- 
plicated case. He is of the opinion that injury to the pneumogastric 
was a frequent cause of death on the field among those hit in the neck. 
The staff of A Civilian War Hospital reports a case as follows: "A 
private was shot through the right orbit at Magersfontein, the bullet 
traversing the jaw-bone and palate, and emerging through the left 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 209 

side of the neck just at the back of the thyroid cartilage. There was a 
complete paralysis of the vocal cord, followed by atrophy of the mus- 
cles, which could only have been caused by a wound of the pneumogas- 
tric nerve, but the patient had no other symptoms which could be 
attributed to such an injury, and made a good recovery. " 

Wounds of the neck high up are apt to involve the hypoglossal as 
well as the pneumogastric. Hirsch 1 reports a case in which the ball 
lodged opposite the fourth cervical vertebra as shown by the skiagram. 
The hypoglossal involvement was shown by atrophy of one-half of 
the tongue, and the pneumogastric injury caused paralysis of the left 
vocal cord and a continued high pulse, 108. 

The pressure symptoms of vagus involvement will be more fre- 
quent with the use of the new military rifle, since aneurysm is now 
more often noted after wounds of the vessels by the small-caliber 
bullet. 

Roswell Park and Makins 2 have shown that the vagus can be cut in 
operative wounds, and immediately sutured, with incomplete tem- 
porary loss of function. 

Wounds of the Cervical Sympathetic. — From the intimate anatomi- 
cal relation of the cervical sympathetic to the great vessels, the pneumo- 
gastric, the cord, air passages, and esophagus, uncomplicated injury to 
the nerve is seldom seen. In those cases of vessel injury in which recov- 
ery has taken place, the characteristic symptoms of cervical sympa- 
thetic injury have been noted. The symptoms which appear only upon 
complete division of the nerve are as follows: (a) Narrowing of the 
palpebral fissure, (b) sinking in of the eye-ball, (c) contracted pupil, 
(d) loss of the cilio-spinal reflex, (e) redness and dryness of the skin 
of the corresponding side of the face. In partial injury to the nerve 
only some of the foregoing symptoms appear. Reddening of the cheek 
is one of the symptoms rarely seen. Excessive flow of tears sometimes 
occurs and it generally proves to be the most annoying symptom. In 
a certain proportion of cases the symptoms are permanent. Larrey 
and Weir Mitchell have reported very interesting cases of wounds of 
the cervical sympathetic in war. Stevenson states that Col. Holt has 
reported several cases from the Boer War, in which the three most 
prominent symptoms were " increase of the sweating, myosis, and 
pseudoptosis (narrowing of the palpebral fissures) on the side of the 

1 Hirsch, Traumatic Injury of the Pneumogastric Nerve, etc., N. Y. Med. J., 
Vol. LXVI. 

2 London Lancet, May 16, 1896. 

14 



210 



GUNSHOT WOUNDS 



injury." Holt adds that " marked cardiac rhythmic disturbance and 
subconjunctival hemorrhage were ascribed to injury of this nerve." 

The staff of A Civilian War Hospital notes the following case in 
the same war: " A private was shot through the right side of the neck, 
the bullet entering at the middle of the left cheek, and passing out 1 1/2 
inches to the right of the spinous process of the seventh cervical vertebra. 
The left eye-ball showed the typical retraction of the globe within the 
orbit, the diminished palpebral fissure, and the paralysis of the dilator 
muscle of the iris characteristic of paralysis of the sympathetic nerve." 
Wounds of the Brachial Plexus. — These are among the more 
common nerve injuries cf the neck. They are often followed by an- 
noying symptoms of irritation in 
the way of hyperesthesia or pain. 
The following case of brachial 
nerve injury occurred at the 
battle of Santiago. The injury 
is typical of the hairbreadth 
escapes which we sometimes 
observe with the use of the new 
armament. 

Captain C. W. T., 9th U. S. 
Cavalry, was shot during a plung- 
ing fire July 2, at about 300 
yards, while locating the enemy 
and estimating the range for his 
men who were lying down. The 
bullet, a Mauser, entered the left 
side of the neck on about the level 
of the upper border of the thyroid 
cartilage and just internal to the 
sterno-cleido-mastoid. The bul- 
let's course was downward, back- 
ward and obliquely to the right, 
making its escape from the body 1 inch to the right of the spine of 
the seventh cervical vertebra. He fell heavily to the ground and 
a sergeant who was near thought him dead. He remained uncon- 
scious for a few minutes only. He was admitted to the Reserve 
Divisional Hospital on the third of July, complaining of pain in the 
distribution of the left median nerve; the neck and left arm were swol- 
len and stiff. The author again examined this officer in December, 




Fig. 116. — Photograph of cadaver show- 
ing course of bullet in case of Capt. C. W. T., 
9th U. S. Cavalry. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 211 

and off and on for four years thereafter. He was never free from 
hyperesthesia, formication, numbness, and neuralgic pains of the left 
arm and hand. The grip of the left hand was about half the power 
cf the right. Judging from the course of the bullet and the persist- 
ency with which the symptoms of irritation continued, the projectile 
more than likely perforated the transverse processes of the fifth and 
sixth cervical vertebra?, injuring the corresponding cervical nerves, 
and passing between the spines of the sixth and seventh vertebrae it 
emerged an inch to the right of the latter. The force of impact which 
caused the officer to drop so lifeless when shot would indicate that the 
spinal cord had received a momentary shock from the transmission of 
the bullet's energy at high velocity. (Fig. 116). 

Wounds of the Air Passages. — Wounds of the larynx and trachea 
by the old armament were not commonly seen in military hospitals. 
The proximity of the great vessels and spinal cord made it difficult 
for a bullet of large caliber to traverse the air passages without causing 
injury of a fatal kind to either the vessels, the cord or both. Chenu 
gives but one example of cure from gunshot of the larynx in the Cri- 
mean War, and that was complicated by a fistula. Otis' table referred 
to shows that the air passages of the neck were included in but seventy- 
seven of 4895 gunshot wounds, or 1.7 per cent, for all neck wounds 
treated. The mortality of tracheal and laryngeal wounds treated was 
practically the same — 50 per cent. 

Wounds of the larynx and trachea that reach hospitals are as a 
rule disposed transversely across the neck. Perforating shots of the 
neck from large calibers directed antero-posteriorly or those travers- 
ing the neck behind the air passages are very likely to injure the great 
vessels or cord with fatal results. Oblique, antero-posterior, or postero- 
anterior shots with low velocity, effecting lodgment, are mentioned 
by Otis and others as capable of injury to the laryngo-tracheal tube 
without fatal issue. The prominence of the larynx and trachea leaves 
them exposed to all transverse shots across the neck anterior to the 
vessels and it was to this class that the hospital cases belonged 
formerly. 

The beneficence which has come from a reduction of caliber is \ 
particularly shown in neck wounds including the laryngo-tracheal 
tube. Military surgeons in recent wars have repeatedly referred to 
the rapid recovery of uncomplicated larynx and tracheal wounds by 
reduced-caliber bullets. Follenfant 1 reports thirty-three cases in the 

1 M. Follenfant, Arch, de Medecine et de Phar. Mil., No. 48, p. 84, 1906. 



212 



GUNSHOT WOUNDS 



Manchurian campaign with three deaths. Ten cases were discharged 
cured and nineteen were transferred. 

Oettingen, 1 who commanded a Red Cross hospital on the Russian 
side in the same campaign, states that the number of tracheal wounds 
was small, that none proved dangerous. In those cases where large 
vessels were involved or in cases from shrapnel or large missiles trache- 
otomy was indicated, otherwise the treatment was expectant. 

Hemorrhage and asphyxia are the immediate dangers to life which 
present themselves in wounds of the air passages. The hemorrhage 

arises from the neck vessels when they 
are injured, and asphyxia results from 
the escape of blood into the smaller 
bronchioles and air cells of the lungs. 
Later, pneumonia and edema glottidis 
sometimes arise. As a sequel stric- 
ture of the larynx or trachea occurs 
in a certain proportion of cases. Pvt. 
Jacob H. Mose, Co. A, 4th U. S. In- 
fantry, was shot by a Mauser bullet 
before Santiago, July 2, while he was 
lying down. "The bullet entered 
right temple 2 1/2 inches above and 
1 inch posterior to the right canthus. 
It passed through the superior maxilla 
downward and backward, cut 2 through 
the posterior portion of the soft palate 
and entered the neck. Here it became 
deflected, probably by the thyroid 
bone, and entered the thyroid cartilage, 
thoroughly comminuting it, cutting into the esophagus wall where, 
being spent, it dropped into the stomach. " The patient states that 
he subsequently passed the bullet per rectum. There was profuse 
hemorrhage from the mouth and nose. He experienced difficulty in 
breathing and swallowing. The difficulty in breathing became so ag- 
gravated that it was necessary to perform tracheotomy August 3. 
He is still wearing the tracheotomy tube. There is complete obstruc- 
tion in the larynx. His voice is heard in a whisper when the finger is 

1 Walter von Oettingen, Studien auf dem Gebiete des Kriegs-Sanitats-Wesens 
im Russisch-Japanischen Kriege, 1904-1905. Berlin, 1907. 

2 Dr. Emil Meyer, Meeting A. M. Association, 1900. 




Fig. 117.— Photograph of J. H. Mose, 
March 4, 1911, at which time he was 
still wearing tracheotomy tube. 



GUNSHOT WOUNDS OF THE HEAD, FACE AND NECK 213 

pressed over the tracheotomy tube. The laryngoscopic appearances 
are described in Dr. Meyer's article. 

Treatment. — Wounds of the larynx and trachea need prompt 
attention on surgical lines. Wounds of the front segment of the 
trachea without undue loss of substance are best treated by suturing 
if the respiratory efforts will permit. Tracheotomy is in order in 
all cases where dyspnea is present. Bleeding from injured vessels 
should be arrested by ligation and when the esophagus is wounded, 
if there is much difficulty in swallowing with extravasation of food in 
the tissues of the neck, feeding should be done through an esophageal 
tube introduced into the stomach through the mouth, or a small 
flexible catheter may be passed through the nose into the stomach. 
Whenever the wound in the esophagus is exposed and permits suturing 
this should be done, leaving provision at the bottom of the wound for 
drainage. Cellulitis being a frequent accompaniment of neck wounds, 
provision for drainage is never amiss in the application of the primary 
dressing. 



CHAPTER VII 

Gunshot Wounds of the Spine 

Of all cases of gunshot wounds that live to receive hospital care, 
those suffering gunshot fracture of the spine are the most fatal, not 
excepting gunshot fractures of the calvarium. 

Out of 642 gunshot fractures of the spine during the Civil War, 
in his concluding observations, Otis places the mortality in the aggre- 
gate at 55.5 per cent. He shows that the fatality increases as the 
seat of injury approaches the head as follows: 

Cervical spine 70 per cent. 

Dorsal spine 63 per cent. 

Lumbar spine 45 . 5 per cent. 

In the German reports for the Franco-German War, 1870-71, 
the fatality on the contrary diminishes with proximity of the injury 
to the head as follows: 

Cervical spine 61 . 3 per cent. 

Dorsal spine 70 . 9 per cent. 

Lumbar spine 71 . 9 per cent. 

These figures fairly represent the mortality for the preantiseptic 
era when the large low-velocity projectiles were in use. Although 
we have not yet received authentic figures of the mortality in spinal 
fractures for the great war in Manchuria, we have enough evidence 
from the Spanish- American and Anglo-Boer Wars to show that the 
use of antisepsis, and the employment of the so-called humane small- 
caliber bullet, have given us little if any encouragement looking to 
the reduction of the old-time mortality in gunshot fractures of the 
spine. The results in thirty-six cases gathered from the Spanish- 
American War and Philippine Insurrection, the majority having 
resulted from gunshot by the reduced-caliber bullet, have given us a 
mortality of 75 per cent, for the spine as a whole. For the Anglo- 
Boer War Stevenson reports the mortality in forty-eight gunshot 
injuries of the spine as follows: 

Cervical spine (5 cases) 60 per cent. 

Dorsal spine (41 cases) 60 . 9 per cent. 

Lumbar spine (2 cases) 00 per cent. 

214 



GUNSHOT WOUNDS OF THE SPINE 215 

He also makes use of the following very significant statement — 
" Fracture of the neural arch and actual lesion of the cord by bone or 
bullet in all regions of the spine taken together give a death rate of a 
little over 78 per cent." This high mortality refers to cases in which 
the lesion was definitely ascertained and it corresponds very closely 
to the mortality in the Spanish- American War just referred to in 
which there is a mortality of 75 per cent, for a similar class of cases. 
These figures establish beyond doubt that the mortality of gunshot 
fractures of the spine has not diminished under modern conditions 
and that it is as great to-day if not greater than formerly. 

There is another significant feature of gunshot fractures of the 
spine which concerns the military surgeon especially, and that relates 
to their greater frequency from the effects of the new, as compared 
to the lesions sustained by the old armament. Borden 1 points out 
that the frequency of the grave injuries of the spine has been more than 
doubled since the introduction of high-velocity jacketed bullets. 
In the Civil War, with the use of the low-velocity lead bullets the 
relative frequency of spinal fractures was 0.26 per cent., while it was 
increased to 0.55 per cent, in the Spanish-American War and to 0.82 
per cent, in the Philippine Insurrection. With the use of low velocities 
in former times, the spine received great protection from its position 
at the back. The comparatively low energy of the old conoidal 
bullets, except at proximal ranges, was sufficiently expended after 
penetrating intervening tissues in front of the spine to ward off fracture 
in the majority of cases, and the injury to the spine more often resulted 
in contusion of the bony structures or lodged balls. The overlying 
layers of tissue like the abdominal wall, abdominal contents, the 
thoracic walls, thoracic viscera, etc., are still a protection against 
spinal injury from low-velocity projectiles of all kinds, viz., spent 
balls, shrapnel and shell fragments. The protective layers mentioned, 
however, are as nothing to ward off fracture with the use of a small 
jacketed bullet, the caliber of a lead pencil, traveling at high velocity. 
Such a bullet except when it is operating as a spent ball is not deflected. 
Its course is forward and onward in a direct path. The bony spine 
itself offers but little hindrance to its penetrating effects. When it 
chances to strike the body of a vertebra, which is made up of can- 
cellous tissue, it makes a clean-cut perforation with little or no splin- 
tering. The compact substance of the neural arches, the spines and 

1 American Practice of Surgery by Bryant and Buck, Lt.-Col. W. C. Borden, 
U. S. Army. 



216 GUNSHOT WOUNDS 

transverse processes are splintered more often transversely as shown 
by Delorme 1 and the amount of shattering is in proportion to the 
velocity of the missile and the resistance encountered. The bullet 
itself or secondary missiles like spicula of bone or metallic particles 
from the bullet traverse the canal or the immediate vicinity of its 
bony walls with readiness, inflicting direct or indirect injury propor- 
tional to the remaining velocity of the projectile at the time of impact. 

Concussion of the Cord by Large-caliber Bullets. — In former 
times the anatomical lesions of the spinal cord, produced independently 
of direct traumatism by the ball or fragments of bone, were appre- 
ciated by the surgeons of our Civil War, as pointed out by Otis, and 
discussed by Lidell 2 of the Volunteer Army. The concussion was 
attributed to impact of the bullet against the spine. The symptoms 
were varied, from motor enfeeblement of the lower extremities with 
numbness, and sensations of "pins and needles on the one hand, to 
complete paraplegia, both motor and sensory, with priapism and 
retention of urine and feces on the other." Lidell adds further that 
"as the symptoms of concussion of the brain result directly from 
cerebral 'shocks/ so the symptoms of concussion of the spinal marrow 
result directly from sudden 'shock' of that organ." It was then 
believed that concussion of the brain and cord were both attended by 
minute extravasations of blood. It is doubtful if neurologists now 
believe that extravasation of blood is a constant accompaniment of 
the condition attended by temporary loss of consciousness known as 
cerebral concussion. On the other hand we believe it is generally 
admitted now that gross structural changes take place in all cases of 
concussion of the cord, so-called, and this is usually shown by the 
slow return of function or by the continuance of the symptoms in 
all cases of spinal cord injury not the result of direct violence. 

Concussion of the Cord by Small-caliber Bullets. — The anatomical 
lesions of the spinal cord independent of direct traumatism by the 
ball or fragments of bone, and the relation which the amount of lesion 
bears to the velocity of the reduced-caliber bullets at the moment of 
impact, have been specially pointed out by Mr. Makins in the Anglo- 
Boer War. He classes these lesions as follows: 

1. Slight concussion. 

2. Severe concussion. 

1 Traite de chirurgie de guerre by E. Delorme, Paris, 1903. 

2 International Encyclopedia of Surgery, Ashhurst, 1884, Vol. IV, p. 788. 
By John A. Lidell, late Surg, of U. S. Volunteers. 



GUNSHOT WOUNDS OF THE SPINE 



217 



3. Contusion. 

4. Hemorrhage. 

5. Intra-medullary Hemorrhage (Hemato-myelia). 

He points out that any of these lesions may be caused by the " vi- 
bratory force communicated to the cord by its enveloping bony canal." 

(1) Slight concussion is likened to the form of spinal concussion 
noticed in civil practice from causes such as railway collisions. The 
cases noted by Makins showed transient symptoms, there were no 
deaths and no opportunity to note anatomical changes. 

(2) Severe concussion results when a bullet traveling at great 
velocity collides with the spine. There is parenchymatous hemor- 
rhage in many of the cases and, 
reasoning upon the vibratory force 
that could induce such a trauma, 
it is assumed that there is more 
or less complete disorganization of 
the cord. The condition produced 
is allied to one of contusion in which 
a localized portion of the spinal cord 
sustains a destructive process suffi- 
cient to " interrupt the normal 
channels of communication with 
the higher centers." In a, number 
of cases cited the symptoms are 
those of complete transverse lesion. 

(3) Contusion. — Mr. Makins 
distinguishes this condition from 
pure concussion though the two 
are " closely allied." In cases of 
contusion the post-mortem condi- 
tions showed adhesion between the 
cord and enveloping dura at points 
where the ball had struck the neural arch without fracture. The 
lesion of the cord which was most marked suggested injury by 
contre-coup. The duration of life was about five weeks. One 
or two segments of the cord were completely disorganized, the 
cord substance was represented by a " semi-diffluent yellowish ma- 
terial of soft consistency." When held up the membranes were 
prone to collapse opposite the affected portion as shown in Fig. 
118. The case to which the figure refers is described as follows: 




Fig. 118. — "Appearance of spinal cord 
enclosed in membranes in case 103 after re- 
moval from the canal. When the mem- 
branes were opened a white custard-like 
substance took place of the cord. Slight 
evidence of extradural hemorrhage existed." 
(Makins.) 



218 GUNSHOT WOUNDS 

"total transverse lesion; slight intra-dural hemorrhage. Wound of 
entry (Mauser), below spine of scapula, close to right axilla; exit, 
2 1/2 inches to left of tenth dorsal spinous process. Complete motor 
and sensory paralysis below ensiform cartilage, with well-marked 
hyperesthetic zone around trunk. All reflexes absent. Retention of 
urine. Incontinence of feces. Bed-sores in sacral region developed dur- 
ing the first two days, and seventeen days later well -developed serpigi- 
nous trophic sores developed on the outer side of each leg and con- 
tinued to increase slowly until death. The paralysis remained of the 
absolutely flaccid variety. Great emaciation occurred, accompanied 
by hectic fever, the temperature ranging from normal to 102.5°. 
During the third week double pleurisy developed. 

"At the post-mortem no bone injury could be detected. The cord 
and dura mater were adherent over an area corresponding from the fifth 
to the eight dorsal vertebrae, and opposite the seventh the cord was 
soft and of the consistence of butter. A small intradural hemorrhage 
was still evident below the main lesion, not extensive enough to give 
rise to serious compression. General adhesions in each pleura. 
Cystitis." 

(4j) Hemorrhage. — This injury as a result of vibratory impulse 
was found in the form of surface extravasations (extra and intra- 
dural) but the more frequent kind of hemorrhage is discussed under 
the next heading. 

(5) Intra -medullary Hemorrhage (Hemato-myelia). — This form 
of hemorrhage was nearly always associated with the changes due to 
concussion. Its frequency was not definitely ascertained, but it was 
more than likely frequent and it is suggested that it was an accom- 
paniment of nearly all grave transverse lesions not due to direct 
injury like compression or laceration. 

In all of his experience in the South African War Mr. Makins 
states that he saw only one case of direct pressure upon the cord by a 
bullet and "none in which this was due to displaced bone fragments. " 
He states further that the transverse lesions which were indicated by 
the symptoms were in his opinion due in nine-tenths of the cases to 
"the conditions of concussion, contusion, or hemato-myelia.' ' This 
opinion based as we believe on sound judgment and sufficient experi- 
ence has a great bearing on the treatment of gunshot of the spine and 
to us it goes far to explain certain cases which we saw during the 
Spanish-American War. 

Concussion of the cord in this respect simulates concussion of the 



GUNSHOT WOUNDS OF THE SPINE 219 

brain which results from molecular vibrations. In the case of the 
more severe concussions of the cord from gunshot the lateral trans- 
mission of energy is so great that there is rupture of the cord sub- 
stance proper with parenchymatous hemorrhage, and the presence of 
symptoms, which mark a transverse lesion, as though the injury 
had resulted from direct trauma. The macroscopic lesions noted 
in such cases arise from the same force that bursts asunder the tins 
filled with water or semifluid contents like starch-paste, as we have 
shown in figures when discussing explosive effects. When impact 
of the missile at high velocity occurs upon the bony structures adjacent 
to the cord and the cerebrospinal fluid, the bullet's energy is trans- 
mitted by them in the form of a vibratory force with Violence in all 
directions, hence the rupture of vessels, disorganization of the paren- 
chyma, and even fracture of the cord itself in some instances. 

Aside from the increased frequency of spinal lesions by the new 
armament, on the score of superior penetration, and direct violence, 
we must credit Mr. Makins for emphasizing the additional explanation 
of the greater frequency of spinal lesions, by the effects of vibratory force 
also. 

What is true of the effects of vibratory force from the projectiles 
of the present-day military rifle in producing the various degrees of 
concussion of the cord, is also true of the effects of vibratory force 
conveyed to the cord from the larger and more perfect revolver 
ammunition of the present day, and it will become more so still with 
the use of steel-clad bullets now employed in automatic pistols, 
weapons which are fast displacing the use of revolvers in civil life. 
Doctor Rudolph Winslow of Baltimore has recently written a very 
interesting paper 1 with cases in which he conclusively shows that 
serious and even fatal lesions of the spinal cord may be produced by 
revolver bullets as a result of concussion without direct impact, and 
he cites cases in the experience of other surgeons. 

With reference to the cases resulting from the effects of the military 
rifle the evidence cited by Mr. Makins in the South African War is 
most interesting. We had a number of cases in the Spanish- American 
War that could only be explained on the theory of spinal concussion. 
The following history of First Lieut. A. S., 13th Infantry, was obtained 
from the records of the hospital ship Relief: " On July 1, while stand- 

1 Complete Transverse Destruction of the Spinal Cord from pistol wound, 
without penetration of the Spinal Canal, by Rudolph Winslow, M. D. Trans- 
actions Southern Surgical and Gynecological Association, 1910. 



220 GUNSHOT WOUNDS 

ing with his company at the foot of a hill during the advance on 
Santiago, received a wound in the neck probably from a Mauser bullet. 
The bullet entered on the right side just below the inferior maxillary 
bone, 1 inch in front of the angle of the jaw. The wound of entrance 
is a clean-cut hole the size of a lead pencil. The course of the bullet was 
backward and slightly downward, emerging at the back of the neck on a 
level with and to the left of the fifth cervical vertebra. At the time 
of the injury felt no pain at the site of the wound but says that the 
sensation was as if he had been grasped by the wrists and thrown 
violently to the ground. The wound of exit is similar to the wound of 
entrance. There was very slight hemorrhage. A few minutes after 
receiving the injury was carried from the firing line by members of his 
company. Removed to the first Division Hospital and during this 
time was conscious of his wound for the first time. Was kept there 
for ten days and then removed in an ambulance seven miles over a 
bad road to the third Division Hospital at Siboney." 

We examined him July 10, and found his condition very much as 
described by the surgeon on the Relief on July 11, which reads as 
follows: " Patient was voiceless and making constant efforts to clear 
his bronchial tubes of accumulated mucus. Complete paralysis of 
right arm and leg and partial loss of power of left arm and leg. Grip 
of left hand very feeble. Respiration normal but an almost constant 
spasmodic cough. Has lost control of sphincters and has involuntary 
passages from both bladder and bowels. In a very exhausted 
condition and has profuse diaphoresis. Complains of pains all 
over body. Ordered a hypodermic of morphia, gr. 1/4 and atropin 
gr. l/100. ,, 

"July 14: Radiograph taken by Dr. Gray shows an injury of 
one of the cervical vertebrae, probably the fifth. Injury seems to be 
to the left side of the body of the bone. Has received no treatment 
other than complete rest and a nightly hypodermic as noted above, 
which gives a good night's sleep and markedly reduces the sweating. 
Has regained control of the sphincters and is able to use bed pan and 
urinal.' ' 

"July 19: During the past six days there has been a decided 
improvement in the general condition of the patient. He is brighter 
in appearance, he can articulate more distinctly and there is a decided 
return of power in the right leg. The right hand is still absolutely 
powerless but the grip of the left hand is stronger. Appetite is good and 
bowels require to be moved with enemas. Unable to sleep without 



GUNSHOT WOUNDS OF THE SPINE 221 

morphine but the atropin has been discontinued. Circulation 
apparently unimpaired.' ' 

"July 21: Improvement in general condition still continues. The 
external wounds have healed so well that they are not noticeable ex- 
cept on close inspection. The hypodermics have been discontinued 
and trional and sulphonal substituted." 

"July 22: Transferred from hospital ship Relief to hospital, 
Fort Porter, N. Y. The subsequent history of the case shows a gradual 
restoration of function of arms, legs, and sphincters. This officer had 
recovered sufficiently in the course of a year to be detailed as instructor 
in one of our military schools. He was later retired the service and 
died January, 1906, 7 1/2 years after the injury, cause not stated. 
We have every reason to believe that the lesion in this and the follow- 
ing case was due to vibratory concussion of the cord as described by 
Mr. Makins." 

Pvt. A. F., Co. "C", 21st Infantry, shot at battle of Calamba, 
P. I., July 30, 1899, by a Mauser bullet distance 250 yards. The 
bullet entered right chest above nipple, over fourth intercostal space 
and passed downward, backward and to the left, emerging from 
back 1 inch to the left of the second lumbar spine. Left leg totally 
paralyzed immediately after injury, hemoptysis two days later. 
Wound healed rapidly without suppuration. Sensation returned in 
leg two months after injury and motion also returned in the course 
of another month. Examination by the writer in May, 1901, revealed 
weakness of the left leg as compared to the right, pains shooting down 
left leg and into corresponding big toe. Patellar reflex absent on left, 
increased on right side. Ankle clonus absent on both sides. Plantar 
reflex absent on left side. The patient was improving when last seen 
some months later. 

Symptoms. — The symptoms of gunshot injuries of the spine may 
be divided into those pertaining to lesion of the vertebrae without 
cord involvement, and those with cord involvement. 

Symptoms without Cord Involvement. — This form of injury was 
more evident by the presence of signs and symptoms from the effects 
of the old, larger-caliber lead bullets. As a rule the degree of com- 
minution and displacement increases with the caliber and weight of 
the missile, and danger to infection is greater. Fracture of the neu- 
ral arches without cord involvement rarely occurs, while fracture of 
the centra or processes is apt to occur without cord involvement when 
the velocity of the bullet, whether it be a large or small caliber, is low. 



222 GUNSHOT WOUNDS 

As stated already, lesion of the centra by the reduced-caliber bullet 
is attended with perforation and no splintering, and, except when the 
bullet is animated by high velocity, there is no cord involvement 
unless the perforation communicates with the spinal canal. Many 
cases of vertebral injury are apparent only from a study of the track 
of the bullet as determined by direction of the wounds and 
the position of the body at the time of injury. Separation of the 
spinous processes may be indicated by deformity, pain on pressure, 
mobility and crepitation. Angular deformity is rare in injuries by the 
reduced-caliber bullet, compared to the lesions by the old-time pro- 
jectile of larger caliber of the Springfield rifle type. One or more 
vertebrae may be implicated, and in the wars of to-day when men do 
much fighting in the prone position, sagittal wounds involving a num- 
ber of the processes or bodies are common. Injuries to the nerve roots 
will be discussed in the chapter on Injury to Nerves. 

Symptoms with Cord Involvement. — The symptoms of vertebral 
lesion with cord involvement from gunshots are the same as those in 
fracture-dislocation, observed in civil hospitals from other causes. 
Like the latter the symptoms vary with the region injured. Generally 
speaking they may be summed up as follows: When the spinal cord 
suffers violent concussion, laceration, or compression, as a result of 
gunshot there is more or less shock with complete paralysis below the 
seat of injury which takes place at once. The paralysis includes all 
muscles supplied by the injured segment and the segments below. 
Lesion of the cervical region is attended with paralysis of the upper 
and lower extremities. If the dorsal region is implicated, paraplegia 
takes place. In partial lesions one arm and one leg may show a greater 
degree of paralysis. Again the paralysis may show itself chiefly in 
both arms, or chiefly in one arm, or leg. As a rule complete paralysis 
follows extensive lesions, which continues till death. At times the con- 
dition is that of complete paralysis of the extensors, and from the first 
there is ability to flex the fingers and toes, or the ability to do so may 
manifest itself later. The type of paralysis varies with the extent of 
the injury and the location thereof. In the lower lumbar and sacral 
regions the form of paralysis is flaccid with tendency to atrophy. At 
higher levels the tendency in extensive cord lesions is for the paralysis 
to be flaccid at first only, later as recovery takes place it assumes the 
neuron type. There are sensory symptoms which consist of hyper- 
esthesia, anesthesia, numbness, formication or a sensation of pricking 
with pins and needles. The pain which is usually local may be in- 



GUNSHOT WOUNDS OF THE SPINE 223 

tensified by movement. Oftentimes there is no pain. Radiating pains, 
generally brought on by movement of the extremities, are apt to occur 
in cases of partial paralysis, more especially of the arms. The ap- 
pearance of numbness, tingling and pain to touch, in a case of complete 
loss of sensation, are regarded as of favorable prognostic value. In 
severe cases there is often the so-called girdle sensation, which results 
from a zone of hyperesthesia immediately above the limit of total 
anesthesia. The thermic sense is sometimes lost or diminished, 
while the sense of touch still exists. When anesthesia is permanent 
the chances of recovery are bad. The reflexes are diminished or 
abolished when the lesion is located in a region of the cord in which the 
reflex emanates. For instance in lesion of the lumbar region the knee 
jerk is diminished or entirely absent. In the same way the cremas- 
teric, plantar, and other reflexes when diminished or absent point 
to the particular part of the cord involved. 

Genito-urinary symptoms refer to those of the bladder. Retention 
of urine is a common symptom in a large percentage of spinal-cord 
injuries. This is later followed by incontinence due to overflow. 
When the paralysis persists, instrumentation becomes necessary, this 
sets up cystitis as a rule, and the latter tends to alkaline urine and a 
tendency to the formation of vesical calculi. Sexual sensations are 
usually lost. Priapism is frequent in severe injuries of the cord 
substance, and also when the lesion is located in the cervical region. 

Herpes zoster is an occasional trophic symptom. The paralyzed 
limbs are apt to be dry and scaly, and the growth of the nails is impaired. 
Decubitus is the most important of the trophic symptoms. It is 
most frequent over the buttocks, heels and external malleoli, the 
elbows and shoulders, parts where pressure is constant. Bed-sores 
develop rapidly, as early as the first twenty-four hours in some cases. 
Sloughing is assisted by infection and it is very rapid in the surrounding 
tissues. Septic fever generally hastens the termination of the case. 
Cyanosis is prone to occur, especially in lesion of the lumber region. 
The temperature is elevated early in the history of some cases and it 
ascends with the height of the lesion in the cord. In cervical lesions 
it registers as high as 108° F. a few hours after the injury. 

Dryness of the lips and mouth with sores on the lips sometimes oc- 
curs but the distention of the intestines by gas is the most important 
symptom relating to the digestive system. It is a serious symptom 
at times because of the hindrance which it offers to respiration. It 
occurs when the lesion is located in the cervical and dorsal regions, 



224 GUNSHOT WOUNDS 

and it never results from lumbar and sacral lesions. It does not appear 
until about twelve hours after the receipt of the injury. Constipation 
is the rule but incontinence of feces may supervene later. 

The pulse is at first accelerated and full, and it may intermit. 
The respiratory symptoms come from paralysis of the muscles of 
respiration and inability to relieve the accumulation of mucus in the 
larynx and trachea. Later edema and congestion of the lung, fruitful 
causes of death, are apt to supervene. Contracted pupils are common 
in lesion of the cord in any region. When the cervical sympathetic 
is involved, as pointed out already when discussing lesions of this 
nerve in the neck, there is narrowing of the palpebral fissure. 

Diagnosis. — The diagnosis of spinal-cord injury will necessarily 
rest upon a consideration of the symptoms just noted. In addition 
X-ray evidence may assist in detecting the site of pressure by spicula 
of bone or lodged missile. 

Prognosis. — A guarded prognosis should be given in all cases, 
even in those where the symptoms point to slight injury. When the 
lesion is pure concussion or the result of parenchymatous hemorrhage, 
the remote effects are difficult to foretell; and the danger of secondary 
changes in the cord are to be remembered. Meningeal hemorrhage, 
independent of complications like meningitis, is not specially fatal. 
Medullary hemorrhage, causing but partial symptoms of transverse 
lesion, may end in recovery, with remote and ulterior disabling conse- 
quences. Pressure from spicu 1 ^ of bone is unfavorable, when the 
ball passing adjacent to the cordis animated with a high velocity. 
Pressure from a lodged missile is not necessarily fatal, if the symptoms 
of transverse lesion are incomplete, and secondary changes remain 
absent. The remote effects in the following case of injury to the 
lower part of the cord make it worthy of mention: Mr. Edward M., 
New York Journal reporter, was shot, July 24, by a Mauser bullet at 
Las Guasimas during the advance on Santiago. The bullet entered 
the back 1 inch to the left of the spine opposite the sacro-lumbar 
articulation. There was immediate and complete paralysis of motion 
and sensation of the lower extremities. We transferred the patient 
from the Reserve Divisional Hospital at Siboney to the hospital ship 
Olevette June 9. He entered St. Lukes Hospital, New York, July 20, 
for paraplegia and partial anesthesia as a result of the gunshot wound. 
A radiograph taken at this time showed the bullet lodged butt end 
foremost 1 inch to the right of the first lumbar vertebra. August 13 
he was able to move the right leg. August 17 Dr. Abbe performed a 



GUNSHOT WOUNDS OF THE SPINE 225 

laminectomy in the lower dorsal and upper lumbar region, cutting 
through the laminae of four vertebrae on one side and breaking the 
laminae on the opposite side. A small spicule of bone pressing on the 
cord was removed. 

He left St. Lukes Hospital October 10 very much improved. He 
was able to walk with assistance; his left leg was weak and more or 
less useless. June 30, 1912, fourteen years after the injury, Mr. 
Marshall writes as follows: 



You may or may not know that a year after the spinal operation 
I took matters into my own hands and arranged with other surgeons 
for the amputation of my left leg midway between the knee and ankle. 
The results of this amputation were so good that I was encouraged to 
hope that despite the predictions of my medical friends I might learn 
to walk. I therefore went out to the Michigan woods with a man who 
kept whitewashed steps painted on the grass for me in a row between two 
railings which served in lieu of crutches. After nearly five years, 
practice at these footsteps, I came east again under my own steam, 
carrying only one cane. Since then my health has steadily improved 
and I have hopes that next year I may be able to discard the single 
cane. 



Very sincerely yours, 

(Signed) Edward Marshall. 
Colonel Louis A. La Garde, 

Commandant, Army Medical School, U. S. A. 
Washington, D. C. 
As stated already cervical and dorsal lesions give the worst prog- 
nosis. All cases in these regions, in which the symptoms point to 
transverse lesion, die in the course of about six weeks. The fatality 
in gunshot of the spine is often augmented by the involvement of 
important structures in the abdomen, chest or neck. The causes of 
death are direct or indirect lesions in the upper parts of the cord 
from which the respiratory muscles become involved. Hemorrhage 
in various forms — intra-dural, extra-dural, and hemato-myelia; menin- 
gitis, myelitis, cystitis, pyelitis, surgical kidney, extreme decubitus, 
and septicemia, all figure among the causes of death. 

Treatment. — After the necessary precautions have been taken to 

15 



226 GUNSHOT WOUNDS 

avoid sepsis, the treatment of gunshot of the spine is largely expectant. 
When the wound is located on the back, and inflicted by a shell frag- 
ment or large projectile, the dangers of infection are very much in- 
creased, and the accessible parts of the wound should be carefully 
guarded by frequent dressing, liberal drainage, as well as irrigation, 
if laceration is present. 

Transport of spinal cases should be deferred for the purpose of 
avoiding hemorrhage, if for nothing else, as long as possible, and when 
it becomes necessary to move these grave cases, they are better carried 
on stretchers to the nearest point, where appropriate after-treatment 
may be properly conducted. Whenever practicable, the patient 
should be placed on a fracture bed. The general measures of treatment 
in gunshot cases do not differ from fracture which may have resulted 
from other causes. Constipation should be relieved by enemata and 
appropriate catharsis, as often as indicated. The distended bladder 
should be relieved every six hours by the use of a rubber catheter 
under strict rules to prevent infection of the viscus. Pressure bed- 
sores should be avoided by watchful care, and when threatened they 
should be treated in the ordinary way. Bed-sores of trophic origin 
should be kept clean and frequently dressed. 

Unlike the cases of spinal injury from fracture dislocation in civil 
hospitals, those from gunshot by the reduced-caliber bullets especially 
require no mechanical appliance to maintain extension and counter- 
extension for the reason that as a rule there is no displacement that 
can be detected. 

Operative interference in war wounds of the spine has yielded poor 
results. Now that the transmission of energy from the projectiles of 
the high-power military rifles is known to be a definite factor in pro- 
ducing complete transverse lesion in which concussion, contusion 
without pressure, and hemato-myelia, play the principal role, the 
futility of performing laminectomy, except for very definite reasons, 
is at once apparent. In recent wars those subjected to the knife 
have died as a rule. Possibly the operation did not hasten the end, 
but we know that in the large majority of the cases no operation was 
indicated. Follenfant 1 informs us that in five primitive laminectomies 
which he saw at Moukden, death occurred rapidly. He saw no 
secondary operations. The experience of the British surgeons in the 
Anglo-Boer War was no better. We did no laminectomies following 
the battle of Santiago, as nearly all the cases in which the cord was 

1 Op. cit. 



GUNSHOT WOUNDS OF THE SPINE 227 

seriously involved with fracture died before reaching hospitals, or 
soon thereafter. 

In the light of our present knowledge, an operation such as a 
formal laminectomy is only indicated when symptoms of irritation 
and compression are present. Compression from blood clot may be 
indicated by the clinical history, and compression from spicula of 
bone or a lodged missile may be indicated by the history, and X-ray 
evidence as well. 

Surgeons are often tempted to perform exploratory operations in 
gunshot of the spine, and yet Mr. Makins informs us that he saw but 
one case in his whole series in which it " seemed possible to regret 
the omission of an exploration." 



CHAPTER VIII 

Gunshot Wounds of the Chest 

With the use of the old armament chest wounds numbered 8 per 
cent, of all wounds treated in war hospitals. This percentage is 
greater with the use of the new armament and the present-day field 
tactics, which favor fighting in the prone position behind shelter 
during which the upper part of the body is more frequently and longer 
exposed. There is also reason to believe that the mortality from 
internal primary hemorrhage will be greater on the field of battle 
than formerly as a result of the clean-cut character of the wounds 
of the larger vessels in the chest. 

The mortality for all chest wounds was comparatively large in 
the days of the old armament. Otis places it at 27.8 per cent, for the 
Civil War. This includes wounds of the thorax, contused, non- 
penetrating and penetrating wounds of the chest. Under modern 
conditions this fatality was reduced to 9.5 per cent, in the Spanish- 
American War. At Santiago we found gunshot wounds of the chest 
to be the most favorable of all trunk injuries outside of the heart and 
great vessels. We believe this to be the experience of the majority of 
surgeons in recent wars. 

For the purpose of more careful study, gunshot wounds of the chest 
are divided into (1) non-penetrating and (2) penetrating. 

Non-Penetrating wounds of the chest include (a) Contusions in 
which there is no laceration or penetration of the skin, and (b) Wounds 
including laceration or penetration of the skin without involvement of 
the pleural cavity. 

(a) Contusions of the chest wall are usually trivial unless the 
force of impact and size oi* the projectile are sufficient to rupture 
underlying tissues, or to fracture bones. Projectiles with a large 
smooth surface have been known to strike and contuse the chest with 
violence enough to rupture the heart, lungs or great vessels, causing 
immediate death. Contusions by smaller projectiles have also been 
known to make such pressure on impact as to cause rupture of vessels 

228 



GUNSHOT WOUNDS OF THE CHEST 229 

in the lung tissue, and visceral pleura with resulting hemoptysis, 
pneumothorax, hemothorax, emphysema, pleuritis or pneumonia. 

Treatment. — Contusions of the chest seldom require active treat- 
ment. When shock and collapse are present the condition should 
be treated accordingly. The chest wall on the affected side should 
be immobilized by strapping. If hemothorax and pneumothorax 
should appear the use of the aspirator is indicated in urgent cases 
with a view to removal of the blood and air. 

(b) Laceration and penetration of the chest wall without involve- 
ment of the pleura in the wound occurred in 11,549 cases out of 
20,364 flesh and penetrating gunshot wounds of the chest in the Civil 
War with a mortality of 1 per cent. Under modern conditions we 
will expect no mortality from this class of wounds. Shell fragments, 
deformed bullets and shrapnel balls are for the most part slow-moving 
projectiles which are prone to lodge, they inflict lacerated wounds 
which correspond in size to the shape and caliber of the missile inflicting 
them. These wounds are usually badly infected and they require 
the special attention of the surgeon to prevent suppuration. At the 
same time that wounds of the chest walls are not fatal, they heal 
slowly because of interference with the process of repair by the 
respiratory movements. 

Treatment of non-penetrating wounds of the chest wall is similar 
to that of simple gunshot wounds. They seldom require more than 
a first-aid dressing. Foreign bodies, lodged missiles, etc., should be 
removed, and strict antisepsis should be practised. Bleeding vessels 
should be tied and when pain is present immobilizing the chest wall 
by strapping will prove very effective. 

In the Santiago campaign wounds of the chest wall by the reduced- 
caliber bullet were often multiple and owing to the projectiles' superior 
penetration, lodged balls were seldom seen. Sagittal, oblique, and 
transverse shots were frequent. In one instance the projectile entered 
the breast above the nipple, emerged below it. It re-entered at the 
costal margin and passing under the skin of the abdomen it emerged 
from beneath the skin above Poupart's ligament. In transverse shots 
the bullet frequently penetrated the arm and chest wall, inflicting 
injury to ribs and cartilage without penetrating the chest or thorax. 

Penetrating wounds of the chest were very fatal in the Civil War 
and the wars fought with the old armament. Otis makes record of 
8715 cases treated with a mortality of 62.5 per cent. The French 
Army had a mortality list of 91.6 per cent, in the Crimea; and the 



230 GUNSHOT WOUNDS 

English troops suffered a mortality of 79.2 per cent, in the same 
campaign. Generally speaking, 60 per cent, of the penetrating gun- 
shot wounds in former wars were fatal. In campaigns which entailed 
privations on account of weather, lack of proper nursing and above all, 
enforced transport in all kinds of uncomfortable vehicles, the mor- 
tality was rated above 90 per cent. The humane character of the 
reduced-caliber bullet in visceral wounds is nowhere better exhibited 
than it is in those penetrating gunshot wounds of the chest that survive 
to reach hospital treatment. Out of 283 cases reported from the 
Spanish-American War and Philippine Insurrection our mortality 
was 27.5 per cent, as compared to 62.5 per cent, in the Civil War. 
Better still, Stevenson reports that out of 214 cases which were treated 
in the Boer War only thirty died, making the death rate 14 per cent. 
The variation in the death rate of these two campaigns may be due 
to the distribution of the relief personnel with the army. With us 
at the battle of Santiago especially, our surgeons had their dressing 
stations close to the fighting line. The severely wounded who would 
ordinarily have died on the field were treated and noted as cases 
belonging to those treated in hospitals. The same explanation holds 
good for the part of the war in the Philippines — our surgeons took 
note of the wounded on the line as soon as they were hit, hence the 
larger percentage of fatalities. 

The humane character of gunshot wounds as revealed in late wars 
was most gratifying to us because, as already stated in another chapter, 
experimental studies of the factors concerned in causing destructive 
effects in wounds had led us to predict a favorable outcome in gunshot 
wounds of the lungs. The small frontage of the jacketed bullets of 
reduced caliber and the minimum amount of resistance in lung tissue 
favor the occurrence of humane wounds. Military surgeons in the 
Anglo-Boer and Russo-Japanese Wars all agree upon this point. 
Oettingen 1 from the Manchurian campaign says that when injuries 
of the lungs were simple, they were among the most harmless of those 
met in war. Follenfant 2 collected the results in 945 gunshot wounds 
of the lungs and pleura in the hospitals at Moukden with a mortality 
of 3.67 per cent. He states that a certain number of officers and men 
were able to resume their duties in a few weeks. Graf and Hilde- 
brandt 3 mention the case of a Chinese soldier who had strength suffi- 

1 Op. cit. 

2 Op. cit. 

3 Graf und Hildebrandt. Die Verwundungen durch die modernen Kriegs- 
feuerwaffen. Vol. II, Berlin, 1907. 



GUNSHOT WOUNDS OF THE CHEST 231 

cient to swim five hours after receiving a fatal gunshot wound of the 
lung. We found it difficult to restrain the patients shot through the 
chest after the battle of Santiago. Many of them had neither dyspnea, 
pain, nor hemoptysis, so that it was difficult for them to understand 
the necessity of keeping quiet. While inspecting the wards of our 
hospital four days after the battle, the beneficence of wounds by the 
reduced-caliber bullet was brought forcibly to our attention when we 
found two soldiers late in the night sitting on the ground engaged in 
conversation over the events of the battle, while smoking cigarettes. 
One of them had been shot through the right lung and the other had 
received a perforating gun-shot of the cranium over the parietal 
region. The latter had been operated upon that day for the removal 
of loose fragments of bone at the wound of entrance. 

We had some remarkable recoveries from gunshot wounds of the 
chest as follows: 

In the case of Pvt. E. 0., Company "C", 16th Infantry, the ball, 
a .45-caliber shrapnel, entered just below the angle of the right scapula 
and coursing forward lodged under the skin in front between the 
seventh and eighth ribs, having penetrated the lung, diaphragm and 
liver. There was hemoptysis for a few days and slight elevation of 
temperature. Lt.-Col. N. Senn, 1 U. S. V., reported the temperature 
normal on the tenth day and recovery seemed near completion on about 
the nineteenth day. 

Pvt. J. B. Senacal, Co. "G", 22d Infantry, was shot by a Spanish 
Mauser bullet on July 1. The bullet entered the back just below the 
angle of the left scapula. It ranged upward through the lung, neck 
and lower jaw, making its escape through the alveolar process opposite 
the right bicuspid, furrowing the tongue. We saw this case shortly 
after the occurrence. He suffered from partial paralysis of the left 
arm as a result of injury to the brachial plexus. There was profuse 
hemoptysis for the first few days. Recovery was uninterrupted after 
the third week. He is living and pensioned at the rate of $30 per 
month. 

Private Harry Mitchel, Co. "C", 7th Infantry, wounded July 1, 
by a Mauser bullet entering over left acromion process, and passing 
through the apices of both lungs. The bullet escaped from the chest 
wall at the fourth intercostal space just above the right nipple. 
There was moderate hemothorax right side. This man made a good 
recovery. He is now pensioned at the rate of $24 per month. 

1 Hispano-American War, letters and papers by N. Senn., Surgeon U. S. Vols. 



232 GUNSHOT WOUNDS 

Henry T. Darby, Co. "D", 13th Infantry, received a gunshot 
wound of the chest on right side from a Mauser bullet July 1. Wound 
of entrance above angle and to outer border of scapula. The bullet 
passed transversely forward and escaped through the fourth intercostal 
space on the left side posterior to the mammary line. He was trans- 
ferred to the hospital ship Relief July 9, at which time Col. Senn re- 
ported his condition as follows: "great difficulty in breathing; he was 

pale, prostrated, temperature 102° F copious pleuritic 

effusion on left side. Chest was opened by an incision through sixth 
intercostal space in the axillary line July 11. About 3 pints of fluid 
blood escaped. Gauze drainage. The lung expanded rapidly and 
the patient commenced to improve. " He was subsequently examined 
for a pension and rated at $30 per month until 1905, when he was 
dropped, whereabouts unknown. 

Symptoms and Complications. — The symptoms of perforating gun- 
shot of the chest are extremely variable. In some cases there are 
but few symptoms. 

Shock is not always present, but it seems to be most marked in 
cases with a pronounced injury to the chest wall. Pain is not constant. 
It is sometimes severe when fractured ribs complicate the chest wound 
and when the pleura is more or less involved in the trauma. 

Hemoptysis is present in about 75 per cent, of the cases, according 
to Stevenson's observation in seventy-eight cases. It lasts three or 
four days as a rule, it is generally scanty and seldom calls for treat- 
ment. Cough is generally slight, and of short duration. 

Hemothorax is a common complication and one of the most serious 
when it is copious and persistent. There is slight hemorrhage in the 
pleural cavity in nearly every case of pleural involvement. Such cases 
are never serious and they are marked by early convalescence. Large 
effusions of blood generally arise from wounds of the chest wall rather 
than the lung tissue. Makins states that hemothorax of parietal origin 
occurs in 90 per cent, of the cases as a result of direct injury to inter- 
costal vessels by the projectile or from laceration by pieces of fractured 
ribs. When it arises from the lung, there is co-existent hemoptysis. 
The onset of hemothorax is gradual as a rule, and it seldom occurs be- 
fore the second or third day. It is a recurrent hemorrhage, and like 
recurrent hemorrhage in other parts of the body it is influenced by ex- 
citement, transport, etc. When the hemorrhage issues from the large 
vessels at the root of the lungs the hemothorax occurs immediately 
and it is rapidly fatal. The symptoms indicating the appearance of 



GUNSHOT WOUNDS OF THE CHEST 233 

hemothorax are rapid pulse, pain, cyanosis, dyspnea, a certain degree of 
restlessness and a rise of temperature which at first is ascribed to absorp- 
tion of fibrin. It has been noted that accessions of temperature occur- 
ring later from time to time may be due to fresh hemorrhage with subse- 
quent absorptions of fibrin and not to sepsis. The remaining symptoms 
of hemothorax are those of fluid in the pleural cavity. Pneumo- 
thorax was a common symptom with the use of large-caliber bullets, 
but it is seldom observed after wounds by the new armament because 
of the very small wounds of entrance and exit in the lung proper. 
Makins saw it in three cases out of about a half dozen wounded by the 
Martini Henry bullet which about corresponds to our old .45-caliber 
450-grain lead bullet shot from the Springfield rifle. But he saw the 
same complication in less than 3 per cent, of perforating chest wounds 
by the reduced-caliber jacketed bullet. Convalescence was slow and 
tedious in those injured by the larger caliber. 

Empyema increases in frequency with the caliber of the bullet 
because the amount of dirt and infected clothing which is carried in the 
wound is in proportion to the sectional area of the bullet. Infection 
may also come from bile and fecal matter when the projectile traverses 
an intestine from below. Secondary infection sometimes takes place 
after aspiration or incision for the relief of hemothorax or removal of a 
lodged ball. Empyema as a result of primary infection by a reduced- 
caliber bullet is uncommon unless the shot is delivered at proximal 
ranges against a rib with shattering of bone. In such a case the 
character of the wound augments the tendency to the development 
of infection from the dirty skin, and possibly from the bullet. 

Pleurisy and Pneumonia. — Pleurisy is very rare. A certain 
amount of consolidation necessarily takes place about the channel of 
a gunshot wound in lung tissue, but pneumonia as a clinical entity is 
seldom seen except in cases followed by exposure. 

Abscess of the lung is rare from gunshot wound. It is commonly 

associated with the presence of foreign bodies like fragments of 

missiles, bone, or pieces of clothing. Lodged bullets have been 

coughed up from abscess cavities with the abscess contents and again 

the abscess about the missile may point outside. Removal of the 

foreign body in any way is generally followed by rapid recovery. 

Gangrene of the lung is a very rare complication. But two cases were 

reported in the Anglo-Boer War, both ending in death. 1 

1 Gunshot Wounds by C. G. Spencer, Major, R. A. M. C. Henry Frowde, 
Oxford University Press, 1908. 



234 GUNSHOT WOUNDS 

Treatment. — The first indication of treatment consists in the 
application of a clean dressing to a clean field. The patient should be 
kept in the prone position and propped up enough to insure comfort. 
Transport should be delayed in all cases until healing has taken place 
and the danger to complications has passed. Our cases at Santiago 
were an exemplification of the evil effects of early transport, as 
pointed out by Greenleaf 1 . He collected the history of twenty- 
four cases in the Santiago campaign, fifteen of whom recovered with- 
out complications. Hemothorax was present in the remainder, and 
in six of these the hemothorax ended in empyema as a result of 
infection. Our wounded were on the move from the time they were 
hit until they were received in the hospitals at the North. They were 
first transferred from the field a distance of ten to twelve miles over 
bad roads in escort wagons mostly. Upon reaching the Divisional 
Hospital at Siboney, they were transferred in small boats in a rough sea 
to transports which had no conveniences for the care of the sick, as a 
rule. The passage to northern points took from five to nine days, so 
that during the active stage of repair the wounds were seldom quiet. 
Makins states that under favorable field conditions hemothorax occurs 
ordinarily in about 30 per cent, of the gunshot cases of the chest and 
that at least 90 per cent, suffer from this complication in varying de- 
grees of severity when early transport takes place. Manteuffel, 2 
Oettingen and all the reporters from Manchuria agree that formal 
evacuation is contraindicated, and they lay particular emphasis on 
the advisability of treating chest cases near the first-aid zone whenever 
practicable. 

Fortunately in the majority of cases the hemothorax is slight and 
requires no active surgical interference. With rest in the prone 
position, and morphine when indicated, absorption takes place in a 
short time. It is a safe rule to delay operation for some days to 
permit healing of the wounded vessels, otherwise removal of the blood 
from the pleural cavity is apt to disturb coagula about the bleeding 
point with a recurrence of hemorrhage. When the blood is suf- 
ficient in amount to embarrass the heart or the respiratory movements, 
it may be removed by aspiration. It is not necessary to remove 
all of the fluid blood. After removing it in part absorption of the 

1 Gunshot wounds of the chest in the Spanish- American War by H. S. Green- 
leaf, Asst. Surg., U. S. A., N. Y. Med. Jour., 1899, No. 70. 

2 Archiv. fur Chirurgie, 1906, p. 711. 



GUNSHOT WOUNDS OF THE CHEST 235 

remainder is often promoted, and if it does not disappear entirely the 
operation may be repeated a second or third time. 

The source of hemorrhage in hemothorax is more frequently from 
the intercostal arteries or the mammaries. The treatment of such a 
condition is ligation of both ends of the bleeding vessel. In cases of 
hemorrhage from an intercostal, pressure by Desault's method which 
is accomplished by pressing the center of a square piece of gauze in 
the wound with the finger and subsequently packing the pocket left 
by the removal of the finger with loose gauze, is a very effective plan 
of treatment. The corners of the gauze originally pressed in by the 
finger are pulled upon to make pressure on the internal surface of the 
wound next to the sternum or ribs. The neck of the sack thus formed 
is twisted and tied close to the chest wall and subsequently transfixed 
by a large safety pin. 

Observations in the present European War point again to the fact 
that hemothorax is one of the most common, and at times one of the 
very serious complications of chest wounds. It may be said also, that 
chest wounds in this war differ in gravity from those in previous wars, 
and that they are attended with hemothorax as a complication more 
frequently than heretofore. 

Colonel Sir John Rose Bradford and Captain T. R. Elliott 1 dwell 
on the change in the characteristic features of the chest wounds ob- 
served in the present war as compared to the wounds in the Anglo- 
Boer War. In the latter, infection of hemothorax was a rarity. 
Makins saw only one case of primary emphysema, and this he attrib- 
uted to the removal of a bullet which lay underneath the skin. There 
were, however, a number of secondary emphysemas due to aspira- 
tion. Secondary infections were also believed to follow resection of a 
rib in order to dislodge intrapleural blood-clots. The surgeons were 
inclined to a most conservative method of treatment. 

The present campaign in Flanders has changed all of this teaching. 
In the Anglo-Boer, Spanish-American, and Russo-Japanese wars the 
bullet wounds were inflicted at the battle ranges by a well-balanced 
ogival-headed bullet. The amount of lesion was generally limited. 
Chest wounds from shell fragments and shrapnel balls were not so 
frequent. In the present war chest wounds are inflicted by the high 
velocity bullets at short range, by fragments of shell, or by shrapnel 
balls. The effusion of blood in the thorax is generally large in amount 
so that it cannot be left alone. The clothing and skin of the soldiers 

1 Brit. J. Surg., 1915, Oct. 15, p. 247. 



236 GUNSHOT WOUNDS 

are fouled with soil and fecal organisms and the result is that primary 
infection is very frequently introduced into the hemothorax. Hem- 
orrhage and sepsis are a much more serious matter in the prognosis of 
chest wounds in this war than in any wars immediately preceding it. 

The observations of Bradford and Elliott were made in base hospi- 
tals at Boulogne, 60 miles from the front and twelve hours distant by 
train. The most of the cases arrived on the second or third day, 
while a few were detained at points nearer the front until the end of 
the first or even of the second week. 

To discover the cause of death, post-mortem examinations were 
made on 84 bodies. Of these, 69 had an effusion of blood in the pleural 
cavity; 23 in this group died of complications such as purulent bron- 
chitis, paraplegia, or additional injuries to the abdominal viscera. 
The remaining 46 died as a result of the hemothorax. The effusion 
was found to be infected in 38 of this number and death in all of these 
was the result of infection. Hemorrhage was the cause of death in 
one case on the third day, and this may have been the cause of death 
in 7 others, but the evidence was not conclusive. 

Death from simple hemorrhage is not to be feared if the patient 
has survived three days, and the authors believe that removal to the 
base does not involve danger of hemorrhage when transport is con- 
ducted after that date. 

In a group of 168 cases made up of mild and severe cases, there were 
27 in which the lung was wounded without evidence of effusion. The 
hemothorax was sterile in 114 cases and 48 of these were so large — 
generally 40 ounces or more — that they had to be treated by aspira- 
tion. Death occurred in 26 cases with effusion, and 20 of these deaths 
resulted from sepsis. One died on the third day as the result of 
simple hemorrhage of the lungs. There were 48 septic as against 
120 sterile effusions, of which 48 were large. 

In another group of 160 cases of hemothorax, in which only the 
severe cases were recorded, but 5 cases of simple wound of the lung 
without effusion were noted. The hemothorax was sterile in 86 cases 
and of these 41 were aspirated. There were 53 septic cases which 
survived after resection. There were 21 deaths and the effusion was 
septic in 16 of these. Again, there was only one death from simple hemo- 
thorax which was complicated by a wound of the heart. The aggre- 
gate was 69 septic as against 91 sterile effusions of which 41 were large. 

A study of the two groups referred to shows that infection was 
present in one-third of the cases recorded and that the large effusions 



GUNSHOT WOUNDS OF THE CHEST 237 

were just as often septic as sterile. The chance of infection has to be 
considered in every case of hemothorax. The authors believe there- 
fore that the wounded men should be moved, as soon as possible after 
the danger from hemorrhage has passed, to a station where the infec- 
tion can be promptly dealt with. (The reviewer is fully in accord 
with the authors as to the necessity of moving the patients at once to 
well-equipped centers where any complication may be intelligently 
dealt with. The transport should be as short as possible and con- 
ducted most carefully. Whenever the field conditions permit it is 
much better to bring the necessary equipment and personnel to the 
patients. Military surgeons generally in all of the recent wars agree 
that formal evacuation of chest cases is contra-indicated and that these 
should be treated as near the first-aid zone as practicable. Sauer- 
bruch and Bor chard, who discussed gunshot injuries of the chest at 
the Congress of German Surgeons held at Brussels, April, 1915, called 
attention to the serious nature of this class of wounds in the present 
war and they are decidedly of the opinion that lung wounds should be 
kept quiet two weeks or longer before transportation is permitted.) 

In the discussion of sterile and septic hemothorax Bradford and 
Elliott bring out some very interesting data. 

Sterile hemothorax. Post-mortem evidence taught them that the 
source of the effused blood cannot be definitely determined during 
life. They seldom saw cases of prolonged hemorrhage or late re- 
sumption of it. They believe that in cases that reach hospital care 
the hemorrhage takes place rapidly and then ceases. 

The fact that a fluid resembling blood is at times removed by aspi- 
ration and fails to coagulate*has elicited much discussion as to the ex- 
tent to which the effused blood coagulates inside the pleural cavity. 
The authors consider it probable that clotting may be interfered with 
by the churning movements of respiration, so that the fibrin is whipped 
out in layers which cover the pleural surfaces while the serum retains 
most of the red corpuscles in suspension. Ordinarily they believe 
the clotting always takes place and very early through the action of 
the ferment liberated at the surface of the wounded tissues. The clot 
may be complete and massive, but with an early and fairly extensive 
separation of the yellow serum from the clot. In such a case as the 
latter, the fluid which separates from the clot is general^ tinted by the 
products of hemolysis or it is a clear transparent yellow. 

Large collections, together with blood causing complete collapse 
of the lung, are rare. There were but 8 cases of pneumohemothorax 



238 GUNSHOT WOUNDS 

out of 328 cases and only 4 cases of pneumothorax without the presence 
of blood. 

Clinical features. — The physical chest signs are the same as those 
to be found with, fluid in the pleura. Dyspnea is one of the early 
and distressing signs and it persists as long as there is a large effusion 
in the pleura. Without extensive effusion it disappears in about three 
days. The temperature rises to 101 to 104° F. However, it falls 
nearly to normal, oscillating between 90 and 100° F. in the next two 
weeks. A high level is rarely shown and unlike the oscillations in 
septic hemothorax it only ranges at most from 99 to 102° F. or 100 to 
104° F., after which it drops to normal. 

Treatment. — The treatment of sterile hemothorax consists in re- 
moval by aspiration of the free fluid when the fluid exceeds 20 to 30 
ounces or when the dullness reaches half way up the scapula. Among 
89 sterile effusions averaging 3 pints in volume aspirated, there was no 
evidence of later hemorrhage, and in but one instance was empyema 
known to develop later. Aspiration should be practised from the 
seventh to the tenth day. A bacteriological examination of all fluids 
removed should be made at once. To control the dyspnea and fits 
of coughing which often supervene during the removal of the fluid, 
by alternately aspirating the fluid and injecting oxygen it is possible 
to empty a chest of all fluid without causing pain. 

Septic hemothorax. — Primary infection is so frequent in this war 
that every hemothorax with fever must be suspected of sepsis. The 
pneumococcus, micrococcus tetragenus, and bacillus influenzae, the 
denizens of the respiratory tract, were the offenders in about 20 per 
cent, of the cases. The remainder had been infected from the skin, 
particles of clothing or part of the equipment carried in with the bul- 
lets, or by dirt which was either normally present on the projectiles 
when they were fired or such dirt as they acquired in ricochet. The 
offending organisms thus acquired were made up of two groups; 
namely, streptococci and staphylococci, and anaerobic gas-producing 
bacilli of fecal origin. The latter abided in 50 per cent, of the cases 
in pure culture or mixed with cocci, and their presence is responsible 
for a very characteristic clinical picture. In 190 sterile cases of 
hemothorax there were 121 bullet and 55 shell wounds. In 77 cases 
which lived there were 33 bullet and 38 shell wounds ; in 35 septic cases 
which died there were 14 bullet and 18 shell wounds. The authors 
insist that early transport does not increase the incidence of infection 
since the septic cases were known to become infected very early. 



GUNSHOT WOUNDS OF THE CHEST 239 

The following points which go far to suggest infection are noted 
among the clinical features: 

1. Fever, developing progressively, or sustained at a steady high 
level, or with widely irregular excursions of temperature. A sterile 
hemothorax may be accompanied by fever lasting as long as three 
weeks, but the daily oscillations as a rule show regular uniformity. 

2. A rapid pulse of 100, 120, or even higher, is customary, but 
severe infection may be present with a pulse of only 80 or 90. 

3. Dyspnea, which is out of proportion to the physical signs and 
increases instead of diminishing. 

4. A furred tongue which tends to be dry and brown with strepto- 
coccal infections. The anaerobic bacilli do not influence fur on the 
tongue. 

5. Sleeplessness. Mild delirium marks a grave and usually hopeless 
infection. 

6. The appearance of pain and tenderness in the side as the pleural 
inflammation developSo Pain caused by fractured ribs or by sub- 
cutaneous emphysema must be excluded. 

7. Vomiting invariably means that abdominal organs as well as 
the lungs have been injured. 

8. The physical signs of a septic hemothorax do not differ from 
those of a sterile effusion, except in the cases where anaerobic bacilli 
are present. The signs are caused by the slow or rapid development 
of malodorous gases as the bacilli grow in the effused blood : (a) rapid 
displacement of the heart; (b) cracked-pot resonance over the bubble 
of gas in the area of dullness of the hemothorax. The gas may develop 
rapidly; the patient may show great respiratory distress, and may 
collapse without high fever. These cases are liable to a disastrous 
error in diagnosis which regards them as an increasing pneumo- 
hemothorax that can only be saved by rest and morphia. 

The foregoing may raise the suspicion of infection. If a case 
fails to show improvement in the general condition, the suspicion is 
thereby increased, but the positive way to obtain evidence of infection 
is by the use of the exploring needle. The sample will show a heavy 
deposit of pus with offensive odor like that of rotten eggs or feces 
pointing to gas-producing anaerobic bacilli. If organisms are not 
revealed in the first examination other samples should be examined 
later. 

Treatment. — Early recognition of infection is very important. 
Much harm results from delay in diagnosis and proper treatment; the 



240 GUNSHOT WOUNDS 

patient's strength is reduced; more or less lasting injury to the chest 
from a thickened inflamed pleura is produced; and fatal septicemia 
may be induced. 

Infected fluid may be removed by aspiration but the entire removal 
of clot and pus is the only desirable resource and this is done by resect- 
ing a rib or two to insure thorough drainage. 

Prognosis. — Cases of anaerobic infections often make excellent 
recoveries. Grave symptoms are of a mechanical nature rather than 
septic, owing to the rapid development of gas. The worst infections 
are the streptococcal cases which may produce a hopeless septicemia. 
In one group, 28 recoveries occurred in men infected by gas bacilli, 
with 7 deaths; while 8 pure streptococcal cases lived, and 3 died. 

The following interesting summary is laid down by the authors: 

1. The total mortality of chest wounds reaching hospital care was 
10 per cent. 

2. Simple hemorrhage never causes death after the third day. 
Sepsis is the principal cause of mortality from this time onward. 

3. Primary infection occurs in 25 per cent, of the effusions and it is 
fatal in one-third of the cases. 

4. A sterile hemothorax should be emptied by aspiration except 
when it is of small size. 

5. Infection should be suspected in all cases which are not pro- 
gressing favorably after the fourth day. It cannot be diagnosed with 
certainty on clinical features alone; a sample of the fluid withdrawn 
should be examined bacteriologically. 

6. A hemothorax fluid which looks red and innocent may never- 
theless be heavily infected. 

7. The chest should be opened as soon as possible in all cases of 
infected hemothorax. 

8. The signs of air as well as blood in the chest may be caused by 
foul gas evolved in the course of an infection by anaerobic bacilli. 
Immediate resection is then required. 

A complete pneumothorax or a large pneumohemothorax due to 
air leak from the lung is not often infected. If infection is present, 
an attempt should be made to expand the lung again by aspiration 
before rib resection is performed. 

Failure of absorption of large quantities of clotted blood should be 
met by incision or the resection of part of one or more ribs and the 
subsequent employment of irrigation. When a hemothorax undergoes 



GUNSHOT WOUNDS OF THE CHEST 241 

suppuration from any cause the treatment is the same as that for 
empyema — incision, resection of rib, drainage. 

All operations for hemothorax should be done under the strictest 
antisepsis with reference to the field, the instruments and dressings, 
to prevent infection of the blood clot, which is proverbially a favorite 
pabulum for the development of septic microorganisms. 

Fractures. — The older writers placed special emphasis upon the 
gravity of penetrating gunshot wounds of the chest when fracture was 
present, and this was considered especially true if the bone lesion was 
at the point of entrance. It was also believed by writers during the 
days of the old armament that a perforating gunshot wound of the 
chest could not take place without fracture. This statement in 
itself shows how common fracture must have been in gunshots by the 
large calibers. Otis states that out of 8715 cases of penetrating gun- 
shots of the chest, fracture of the ribs is noted in 505 cases of which 
204 were fatal. He believes fracture was nevertheless present in the 
majority of the cases. Fracture of the sternum is noted as a complica- 
tion in fifty-one cases, fracture of the vertebrae in ninety-two; of 
the clavicle in 136, of the scapula in 375 cases of the 8715 penetrating 
chest injuries. 

Fracture of the ribs by the reduced-caliber bullets is in the form 
of gutter, or notching of the costal margin. When complete solution 
of continuity takes place the comminution is localized, the spicula 
are small and the fissures are short. The costal cartilages show no 
fracture, they are grooved or perforated. Gunshot of the sternum 
is always guttered or perforated, without fracture. 

Fracture of the clavicle is attended with comminution on account 
of its compact structure and the area of fracture is not so circumscribed 
as it is in fracture of the ribs. In the case of Colonel E. H. Liscum, 
U. S. A., at the battle of Santiago, a Spanish Mauser bullet splintered 
the middle third of the clavicle badly. Spicula of bone were removed 
from the wound shortly after the injury and two weeks later bone 
fragments were again removed and the jagged edges of the inner 
fragment were excised. But 1 cm. of the acromial end remained after 
final healing (Johns Hopkins Hospital records). 

Gunshot lesion of the scapula generally exhibits clean-cut perfora- 
tions with no special features as to symptoms or prognosis. 

Symptoms of Fracture of the Ribs. — Fracture of the ribs often 
shows none of the symptoms of fracture present from other causes, 
such as pain, stitch on inspiration or crepitus. This fact was noticeable 

16 



242 GUNSHOT WOUNDS 

in a number of our cases in the Santiago campaign. The absence 
of symptoms is seen especially in transverse shots through the chest. 
The lesion in such cases may be perforation or notching. In either 
of these lesions there is no raison d'etre for symptoms of pain or 
crepitus. Transverse lesions are frequently marked by complete 
solution of continuity with total absence of bone substance opposite 
the point of impact, so that the fragments fail to touch. In such cases 
crepitus is absent, and most generally pain and stitch on inspiration 
are not complained of. In longitudinal shots complicated by complete 
fracture of two or more ribs the comminution is generally marked. 
In these cases pain and dyspnea are often severe. 

Treatment of Fractured Ribs. — The wound should be explored to 
remove any loose spicula of bone. The chest should be immo- 
bilized at once in all cases. The indications for fixation are especially 
necessary in multiple fractures. 

Lodgment of Bullets in the Chest.— Retained bullets in the 
chest were of common occurrence with the use of the low-velocity 
weapons. Otis in his series of 8715 cases of penetrating gunshot 
wounds of the chest mentions 484 cases of missiles which entered the 
chest and which were believed to have lodged within. His notes 
contain record of 3463 cases in which no mention is made as to exit or 
lodgment. In the wars of the present day lodgment of missiles is 
chiefly confined to shell fragments, shrapnel balls and rifle projectiles 
having low remaining velocities. Missiles usually find lodgment in 
the chest wall, lung, pleural cavity or against the spinal column. 
The exact location of the foreign body is first to be determined by the 
X-ray. No attempt should be made to remove a lodged missile 
unless it causes untoward symptoms. When easily accessible, in the 
chest wall, its removal should be undertaken with full knowledge of 
the risks involved in setting up sepsis of the underlying pleura, and 
even in this location, if the projectile causes no inconvenience it is 
better to let it remain undisturbed lest infection with acute empyema 
result from attempts at removal. After correctly locating a missile 
inside the pleural cavity, if it gives pain and other symptoms of 
irritation, it should be cut upon and removed. Projectiles imbedded 
in lung tissue and against the spine are best let alone. 

Gunshot Wounds of the Heart and Pericardium.— When a gunshot 
wound of the heart occurs, death usually results in a very few moments. 
Still, wounds of the pericardium and heart followed by recovery were 
noted even in the days of the old armament. The marvelous escape 



GUNSHOT WOUNDS OF THE CHEST 243 

of the heart and pericardium from apparent injury in shots traversing 
the cardiac area has been commented upon by nearly all observers in 
recent wars. These cases of unexpected recovery are said to be due 
to the way in which the heart and great vessels are held together by 
loose areolar tissue which favors a certain amount of displacement 
at the moment of impact by a bullet impressed with a low remaining 
velocity. Some of the unexpected recoveries from wounds of the 
cardiac area have also been ascribed to the variability of the size of 
the heart from systole to diastole. 

Follenfant states that Manteuffel saw five cases, and that Doctor 
Butz observed three cases of wounds of the heart in the Manchurian 
campaign which recovered without treatment. Makins from the 
Anglo-Boer War reports that "perforating wounds of the heart were 
probably fatal in all instances, in spite of the fact that in some patients 
who survived, the position of wound apertures on the surface of the 
body made it difficult to believe that the heart had not been pene- 
trated." 

We believe Mr. Makins' statement to be too sweeping. The 
literature of heart injuries contains many references to recovery from 
incised wounds of the pericardium and heart. If recovery from gun- 
shot wounds of the heart were possible formerly, they should be more 
apt to recover now from the lesions inflicted by small jacketed bullets, 
especially those of the 6.5-mm. bullet of the Japanese, or the later 
pointed bullets recently adopted by the English, German and United 
States armies when a regular impact is accomplished. The slit-like 
apertures of entry and exit so often noted in the skin and other tissues 
are not unlike incised wounds inflicted by a knife blade from which, 
as we have already stated, authentic instances of recovery have been 
noted. 

In seventy-two men wounded in the cardiac area Fischer found 
the location of the wound of the heart on post-mortem to be as follows: 

Right ventricle 22 

Left ventricle 16 

Both ventricles 4 

Right auricle 2 

Left auricle 

Apex 

Base 

Septum ventriculorum 

Entire destruction of heart 



244 GUNSHOT WOUNDS 

Symptoms. — Among the symptoms of wound of the heart and 
pericardium are those of great distress, shock, irregular action of the 
heart, syncope, dyspnea and severe pain in the cardiac area. Hemo- 
pericardium when present more often appears some days after the receipt 
of the injury. At first the fluid blood flows through the pericardial 
wound into the pleural cavity or outside. Later when the pericardial 
wound becomes closed by coagula, accumulation of blood in the peri- 
cardium takes place and the symptoms of hemopericardium appear, 
as evidenced by increase of the cardiac area, loss of apex beat, and 
the presence of friction sounds from the inner lining of the pericardium 
rubbing against the coagulated blood. In cases of suppuration the 
symptoms are very similar, with the added presence of an elevation 
in temperature. 

Treatment. — When symptoms point to the presence of blood or 
septic matter in the pericardium with urgent dyspnea, paracentesis 
of the pericardium should be practised to relieve the distress and im- 
pending death. The needle should be inserted 2 inches to the left 
of the median line in the fourth or fifth interspace, pushing it continu- 
ously until no further resistance is encountered, when fluid will 
flow if present. The patient should as a rule be recumbent during 
the operation. The operation may be repeated if it was accompanied 
by relief in the first instance. If pus is present it is better treated by 
open incision and drainage. 

Wound of other Thoracic Structures. — Gunshot wound of the 
thoracic duct does not figure in medical literature. Otis reports no 
instance in the surgical records of our great Civil War, and we find 
but one reference to such a case in the experience of Bonet as quoted by 
Delorme. 1 

Wound of the thoracic portion of the esophagus must be very 
rare. Otis mentions one solitary instance in the Civil War. Spencer 
stated that one case was reported from the Anglo-Boer War in which 
dysphagia was the only symptom, possibly as a result of bruising. 
Injury to the thoracic part of the esophagus in battle is more than likely 
accompanied by spinal or great-vessel injuries or both, cases which 
figure among the dead on the field, hence their rarity in military 
hospital reports. Again, authors cling to the notion that the loose 
tissue of the mediastinum permits structures like the great vessels 
and the esophagus to be pushed aside by the pressure of the bullet. 
This explanation can only be tenable in the case of bullets having 
low remaining velocities. 
!Op. cit., pp. 719-20. 



CHAPTER IX 
Gunshot Wounds of the Abdomen 

No class of wounds has given such divergent results between the 
practice of civil and military hospitals as those from gunshot of the 
abdomen. Our civil confreres had attained results in the surgical 
treatment of abdominal wounds (mostly from pistol shots) which had 
served to lend great hope for the outcome of abdominal wounds in- 
flicted by firearms in modern wars, but alas! this hope was turned to 
bitter disappointment in the Spanish-American War, the first to be 
fought with the use of the new armament. As far as present observa- 
tion and experience have gone, if penetrating wounds of the abdomen 
in the field recover more often than they did formerly, we regret to state 
that it is not through the intervention of surgical care, but rather 
due to the character of the wounds inflicted by the new military rifle 
under certain battle conditions only, and that the skill and painstaking 
details of expert surgeons avail but little in the management of the 
large majority of gunshot wounds of this region. Various reasons have 
been given in explanation of this fact, and we will endeavor in this 
chapter to rehearse the points at issue and to lay emphasis on those 
which appear to us to be chiefly concerned in this unwelcome result. 

Gunshot wounds of the abdomen are very properly divided for the 
purpose of study into: 

(1) Contusions. 

(2) Non-penetrating flesh wounds. 

(3) Penetrating wounds of the abdominal cavity. 

(4) Perforating wounds of abdomen. 

(1) Contusions of the abdomen may be (a) confined to the abdom- 
inal wall, or (b) the contusion may in addition be accompanied by 
rupture or other injury of some of the viscera or blood-vessels in the 
abdominal cavity proper. Simple contusion of the abdominal wall 
may be accompanied by superficial extravasation of blood, hematoma 
of considerable extent, or rupture of muscle fiber. As a result of gun- 
shot in war, the condition is rare as compared to contusion from 
other causes, such as that attending the commotion of battle — vio- 

245 



246 GUNSHOT WOUNDS 

lence from the hoofs of horses, the wheels of field artillery, blows from 
rifle butts, etc. 

Gunshot contusions of the abdomen with or without visceral in- 
volvement are caused by large shot, shells or shell fragments when 
moving at low velocity, or in a direction at a tangent to the surface. 
They also arise from rifle projectiles and shrapnel balls when striking 
with low velocities against the body proper or part of the accoutre- 
ment, like a belt buckle. 

The symptoms of contusion may be attended by rupture of muscle 
which is indicated by a depression between the muscle fibers at the 
point of impact, or there may be tumefaction indicating hematoma. 
Nausea and vomiting are common with falling or rising temperature. 
Shock is not an infrequent symptom, and when the blow is delivered 
in the neighborhood of the solar plexus, as on the belt buckle from a 
spent ball, the shock has been so great in some recorded cases as to 
cause prolonged insensibility, and death. 1 

Contusion with rupture of viscera is rare from gunshot. Otis 
reports forty-one cases from our Civil War with twenty deaths. 
Among these were one rupture of the liver, and one of the spleen, three 
of the kidney, five of the intestines and thirty-one ruptures of viscera 
undetermined. 

In recent wars contusions of the abdominal wall alone and contu- 
sion attended with rupture of viscera have not been of frequent occur- 
rence. They are not referred to by Makins in his Surgical Experi- 
ences in South Africa, while Stevenson refers to fourteen cases from 
various kinds of missiles. A case by Sir Watson Cheyne in the Anglo- 
Boer War and quoted by Stevenson is one of the most remarkable of 
any contusion of the abdomen with visceral injury. " A man was shot 
1 inch above the umbilicus by a rifle-bullet which either was travelling 
at such low velocity or grazed the abdominal wall so obliquely that it 
only removed the cuticle over an area of 1 inch by 1/4 inch, leaving 
apparently the true skin uninjured. The man died on the third day 
from peritonitis, and at the post-mortem two lacerations of consider- 
able size were found in the ileum, immediately beneath the site of 
contusion. The specimen, skin and intestine, is now in the R. A. 
Museum." In our opinion such an occurrence more than likely took 
place by the impact of a spent bullet against the abdomen when the 
intestines were very much distended with gas or fluid contents, more 
than likely the latter. A knuckle of intestine pressing against the 

1 Delorme, op. cit., Vol. II, p. 746-7. 



GUNSHOT WOUNDS OF THE ABDOMEN 247 

wall at the point of impact no doubt received enough of the remaining 
energy of the bullet to cause rupture. 

In the Russo-Japanese War Graf and Hildebrandt 1 state that con- 
tusion with rupture was rare and contracted mostly when the men 
were lying prone, from well-spent balls. When the official reports 
of the great war in Manchuria have been published we will no doubt 
be better able to discuss the frequency of contusion of the abdominal 
wall by the new armament with and without visceral injury. 

Symptoms of contusion of the abdomen with rupture of viscera 
are quite similar to those of contusion of the abdominal wall, but in 
addition there are symptoms of a serious and persistent kind which 
refer to internal hemorrhage, lesion of the intestine, or rupture of 
solid viscera like the kidney, liver, spleen, etc. The symptoms are 
not always definite in the earlier part of the clinical history. 

In the less severe cases, viz., those that live long enough for the 
development of symptoms, there appear in addition to the earlier 
symptoms of shock, pain, vomiting and rigidity of the abdominal wall, 
some later symptoms which point to hemorrhage or peritonitis. The 
significance of these symptoms should not be overlooked because 
they bear on the extent and kind of injury, and because they are 
of much value in the subsequent treatment. In the presence of 
internal hemorrhage, the patient becomes pulseless and very restless; 
pallor and difficult breathing appear and the peritoneal cavity fills 
with blood as evidenced by dullness in the flanks. The dullness will 
vary as it does when present in other cavities, by varying the position 
of the patient. Retention of urine is a frequent symptom in the 
presence of hemorrhage. The source of hemorrhage may be rupture 
of one of the solid organs, a blood-vessel, or the intestine; but most 
generally it results from fracture of the liver or spleen. Peritonitis 
usually follows rupture of some part of the intestinal tract. In such a 
case, the pre-existing tenderness, pain, rigidity and vomiting become 
more intensified, and tympanites becomes more marked. 

The diagnosis of internal injury should be based upon a survey of 
the symptoms. In some cases, the symptoms, at first, are more or 
less misleading since they are in no wise in keeping with the severity 
of the injury; and again, a marked lesion is not always accompanied 
by profound shock, or other symptoms of a grave injury. For instance 
slight contusion of the abdominal wall has been known to coexist 
with severe shock, or the symptoms may be trivial in the beginning, 

1 Op. cit. 



248 GUNSHOT WOUNDS 

when extensive lesion is present. The persistence of the symptoms is 
far more significant than their severity. In a case of rapid pulse, and 
persistent vomiting, with increasing rigidity of the abdominal wall, 
peritonitis from intestinal rupture is almost certain to be present. 

Treatment. — In simple contusion of the abdominal wall the 
treatment is purely expectant. Shock if present is treated in the 
usual way. The patient should be placed in bed with shoulders ele- 
vated and knees drawn up to relax the abdominal muscles. Morphia 
for the relief of pain should be withheld as long as possible since its 
effects are prone to mask some of the important symptoms of visceral 
lesion when present. In the first twenty-four hours it is better to 
depend upon position and fomentations. If opium is to be used in 
any form it should be administered as morphine hypodermatically. 

When the primary symptoms of shock, pain, nausea and vomiting 
persist, or if dullness indicates the presence of blood in the abdominal 
cavity, the abdomen should be opened at once. The sooner this is 
done after a reasonable diagnosis has been made the better will be the 
chances of saving life. Cases of visceral injury from contusion when 
let alone all die; they are more fatal than penetrating wounds by the 
new armament, as we will show later on. For this reason unfavorable 
environment and fear of setting up sepsis by opening the abdomen 
in field hospitals should form no excuse for delaying operation. A man 
dying of internal hemorrhage has only one chance for life and that lies 
in a laparotomy. Laparotomy for impending peritonitis from rupture 
of a hollow viscus is just as imperative. As soon as rupture of any part 
of the intestinal tract becomes known or strongly suspected by the 
persistence of symptoms of tympanites, rigidity of the abdominal 
muscles, and rapid pulse, the abdomen should be opened and the 
ruptures properly sutured, the peritoneum cleansed of blood clots and 
fecal matter. Shock should be combated with appropriate remedies 
including hot salt solution in the abdominal cavity. The operation 
should not be prolonged any more than is absolutely necessary. The 
abdominal incision should be brought together by interrupted silk- 
worm gut to include all layers. 

(2) Non-penetrating Wounds of the Abdomen. — The chief in- 
terest in this class of wounds lies in the difficulty which the surgeon 
often encounters in differentiating non-penetrating from penetrating 
wounds. Thanks to modern methods of treatment there is now no 
mortality attending non-penetrating wounds of the abdomen, since 
they are classed with simple flesh wounds. Of sixty-four cases 



GUNSHOT WOUNDS OF THE ABDOMEN 249 

reported by the Surgeon-General of the U. S. Army during the 
Spanish-American War and Philippine Insurrection there was no 
death, while the death rates in 8612 recorded cases in our Civil War 
and the Franco-German War, taken together, give an average mor- 
tality of 8.3 per cent. 

Non-penetrating wounds of the abdomen are less frequent with 
the use of the new armament because of the greater penetration of 
the new military rifle bullet. They often present difficulty in diagnosis. 
The gutter wounds, and those with superficial tracts, indicate very 
definitely the non-penetrating character of the wounds. In the case 
of a lodged ball its position is easily defined by palpation or by the 
X-ray. The greatest difficulty as pointed out by Mr. Makins was 
found in those wounded in "the thicker muscular portions of the 
lower part of the abdominal and pelvic walls." Wounds of the colon 
and sigmoid flexure so often give no symptoms that penetration of 
them is frequently undetected. 

Treament. — Non-penetrating wounds of all kinds are treated on 
the principles laid down for infected wounds. They should be cleansed 
of shreds of clothing and foreign matter when lacerated and when the 
parts of the wound are easily accessible. In the case of shots trav- 
elling immediately under the skin for any distance it is well to estab- 
lish drainage at different points or to lay the channel open and treat 
the wound from the point of entrance to that of exit as an open 
wound. Missiles when properly located should be removed. Splin- 
ters from grenades are said to cause extensive multiple wounds which 
heal slowly on account of loss of muscular and other tissues. 

(3) Penetrating Gunshot Wounds of the Abdominal Cavity. — 
Under this designation we include those gunshot injuries which 
penetrate the peritoneal cavity without injury to either the omentum, 
mesentery or other viscera. Although this classification is adhered 
to, we recognize that so-called penetrating wounds often include 
injury to the omentum and mesentery. This is no doubt in part 
the class of wounds that has recently come forth in sufficient numbers 
to puzzle military surgeons, and a host of civil surgeons who, for 
love of country, and a desire to ameliorate suffering, have rendered 
valuable service with armies in recent wars. The wounds referred 
to penetrate the intestinal area, but they give no special indication of 
visceral injury, and they often or nearly always recover. The idea 
that a projectile is capable of penetrating the peritoneal cavity 
without injury to the viscera is not new. It is mentioned by the 



250 GUNSHOT WOUNDS 

older writers, who under their expectant plan of treatment had 
reasons to suspect such an occurrence in patients who recovered. 
Otis mentions such cases, and one in particular which was verified 
by post-mortem, in a soldier who died from injury to parts- outside 
the peritoneal cavity as follows: "A round musket ball entered the 
left ninth intercostal space; point of lodgement, body of second 
lumbar vertebra. The bullet traversed the chest, perforating the 
lung and diaphragm, it grazed the stomach, colon and coils of jejunum. 
The soldier survived three weeks. At post-mortem no evidence of 
peritonitis was present. Death was due to lung complications and 
hectic from a psoas abscess." In another case the ball passed obliquely 
across the abdominal cavity through the convolutions of the small intes- 
tines " without apparent injury to any portion of the digestive tube." 

The Kaiserliche Sanitats Bericht, 1870-71, gives strong presump- 
tive evidence of the existence of this class of wounds by the larger- 
caliber military rifles. Of 1534 gunshot wounds of the abdomen 
involving the peritoneal cavity thirty-three are reported to have 
been wounds of the peritoneum alone and in nine of these the bullet 
penetrated the abdomen transversely without injury to the intestines. 
The surgeons in civil practice have frequently noted such cases from 
the effects of low velocity missiles from pistols and revolvers. 

After the introduction of the reduced-caliber rifles it was thought 
that injury to the peritoneum alone might be less frequently observed 
because of the superior velocity of the new bullet, which causes it 
to cut like a knife, but the large number of recoveries in recent cam- 
paigns tends to negative this view. Peritoneal wounds seem to be 
mostly confined to shots about the regions of the jejunum, ileum and 
transverse colon, and not so often to shots over the stomach, duodenum, 
the ascending and descending colons. Shots over the latter, 
and the solid viscera, are more readily suspected of inflicting perfora- 
tion, because of the fixed position of the organs. 

At Santiago we saw men who had recovered from abdominal 
wounds by the Spanish Mauser bullet when the track of the bullet, 
as judged by the location of the wounds of entrance and exit, made it 
impossible for the bullet to have travelled outside of the intestinal 
area. These shots were mostly disposed antero-posteriorly, but in 
one case in particular the shot traversed the abdomen obliquely from 
one flank to the other. The patient recovered without evidence 
of either general or local peritonitis, much to the surprise of the 
surgeons who saw the case. 



GUNSHOT WOUNDS OF THE ABDOMEN 



251 



Various explanations have been given to account for these bene- 
ficent effects of the new bullet. One is that the small intestine is 
suspended by the mesentery in a way to permit free movement, and 
as the coils of gut are superimposed when the bullet's track takes 
certain directions, the missile is able to travel parallel to the long axis 
of the coils without perforation. 

One of the most indubitable instances of gunshot penetration of 
the abdomen which goes far to support the contention that the 
movable intestine is capable of being pushed aside to avoid perforation 




Fig. 119. — Shows the denuded and lacerated intestine in Thornburgh case. 



occurred in the practice of Major R. W. Thornburgh, U. S. A., as 
follows: "Private William Ummack, Co. "H", 30th U. S. Infantry, 
recently entered Letterman General Hospital, San Francisco, Cal., 
for gunshot wound of the abdomen self inflicted. The weapon used 
was the U. S. Army reduced-caliber magazine rifle loaded with a full- 
charge cartridge. Wound entrance 3X2 cm. diameter, located 5 



252 



GUNSHOT WOUNDS 



cm. to left and 2 cm. above the umbilicus. Wound of exit 1 cm. in 
diameter, located directly above left posterior superior spine ilium, 
on a level with umbilicus. There were fifteen wounds of ileum, three 
of descending colon, numerous wounds of mesentery. No complete 
intestinal perforation discovered. Twelve ruptured blood-vessels 
found. Intestinal wounds consisted of destruction of peritoneum 
and muscular coats. Wounds of viscera principally due to explosive 
effect of cone of fire proceeding base forward. Muzzle of rifle was 




Fig. 120. — Shows omentum covering lesion in wound of mesentery in Thornburgh case. 

placed against body, olive drab woolen shirt and cotton undershirt 
perforated by bullet. 

When received at hospital patient was so much shocked that the 
surgeons refrained from doing a resection of the wounded intestine. 
The wounds of the colon were inverted, blood-vessels tied, and the 
wounded ileum and mesentery were covered by omentum as shown 
in Figs. 120, 121. Fig. 122 shows the protruding gut and a piece of 
omentum. Fig. 119 depicts the character of the lesion of the denuded 



GUNSHOT WOUNDS OF THE ABDOMEN 



253 



and lacerated intestine. The patient was drained front and rear 
and placed in Fowler's position with Murphy drip for twenty-four 
hours. There was at no time any infection and a perfectly normal 
convalescence and recovery were the result." 

It is difficult to conceive how the ball and the explosive charge 
could have traversed the abdominal cavity as indicated in the history 
of this case without perforating the intestinal tube except upon the 




Fig. 121. — Shows omentum covering lesion in wound of mesentery in Thornburgh 



case. 



theory of displacement by the pressure which was exerted upon the 
tissues in all directions. That the intestinal area can be traversed 
by a rifle bullet without opening the small intestine seems also to have 
been demonstrated to the satisfaction of the staff of A Civilian War 
Hospital. The authors quote the case of Mr. Lenthal Cheatle as fol- 
lows: " A private was shot right across the abdomen in a fight to the 
west of Pretoria, and died forty-eight hours later. The bullet had entered 
low down in his right lumbar region, and had emerged near the left 
anterior superior spine of the ilium, where it finally lodged, after pass- 



254 



GUNSHOT WOUNDS 



ing through the skin for half its length; it was a " Jeffreys sporting 
bullet." The post-mortem examination showed that the projectile 
had passed through the cecum transversely, close to its posterior wall, 
and had passed out through the sigmoid flexure, in which it made a 
large rent. It was thus clear that the bullet had passed right across 
the cavity of the abdomen, and, having entered it posteriorly and 
passed from behind forward, it had thus traversed the abdomen in its 
antero-posterior diameter as well. In spite of this, however, the coils 
of small intestines showed no wound or abrasion, although there was 




Fig. 122. — Knuckle of gut from wound of entrance and omentum from wound of exit in Thornburgh 

case. 



a most careful search after removing the bowels from the body. 
Other cases might be quoted, but this one is enough to establish be- 
yond doubt the possibility of a bullet traversing the abdominal cavity 
below the umbilicus without wounding the small intestine." 

From the foregoing it may be taken for granted that when a bullet 
traverses the intestinal area without the appearance of symptoms of 
peritonitis the small intestine has escaped perforation. 



GUNSHOT WOUNDS OF THE ABDOMEN 255 

(4) Perforating Gunshot Wounds of the Abdomen. — In this class 
of wounds the peritoneum is not only opened but there is lesion of 
some of the contained viscera. 

Pathology. — The wound of entrance is more often located on the 
anterior surface of the abdomen and this is especially true of wounds 
met in civil hospitals from personal combat. Less often the wound 
of entrance is located on the flank or back. In military practice a 
projectile often enters the peritoneum after traversing distant ana- 
tomical parts. Bullets from high-power military rifles frequently 
enter the buttock, neck or thorax, and subsequently cause perforating 
abdominal wounds. 

Protrusion of the omentum or intestine is common from shell 
wounds and the wounds of the military rifle at proximal ranges. Pro- 
trusions are apt to occur also from the larger calibers; they rarely occur 
as a result of wounds from the present-day military bullets at the 
battle ranges. 

Referring to the order of frequency of wounds of the abdominal 
contents, the small intestines which occupy most of the target area 
rank first, next in frequency come the liver, stomach, large intestine, 
kidneys, spleen, and pancreas. 

The " Deutsche Kriegs Sanitats Bericht found in 192 cases: 

93 injuries to the intestine, 48 . 43 + per cent. 

68 injuries to the liver, 35 . 41 + 

16 injuries to the stomach, 8 . 33 + 

2 injuries to the spleen, 1 . 04 + 

13 injuries to the other organs, 6 . 77 + 

Stevenson found in 161 cases: 



40 
35 
28 
17 
14 
13 
13 
1 



njuries to the colon, 24 . 84+ per cent. 

njuries to the small intestines, 21 . 73 + 

njuries to the liver, 17 . 39 + 

njuries to the bladder, 10 . 55 + 

njuries to the spleen, 8 . 69 + 

njuries to the stomach, 8 . 07 + 

njuries to the rectum, 8 . 07 + 

njury to the pancreas, 62 + 



The American Sanitary Report found among 1092 cases: 

673 injuries to the intestines, 61 . 63+ per cent. 

173 injuries to the liver, 15 . 84 + 

79 injuries to the stomach, 7 . 23 + 

79 injuries to the kidney, 7. 23 + 



256 GUNSHOT WOUNDS 

54 injuries to the blood-vessels and peritoneum, 4. 94 + 

29 injuries to the spleen, * 2. 65 + 

5 injuries to the pancreas, 45 + 

Bullets from military rifles travel in a straight line from the point of 
impact to the point of exit or lodgment, and the organs located in the 
bullets' path are usually perforated. In civil practice, and in the days 
of low-velocity weapons, balls were known to pursue an erratic course. 
The literature on the subject of glancing balls from the resistance en- 
countered in fascia, tissues like bone, tendons, etc., appears incredible 
to us to-day, and such occurrences are no longer considered possible 
with the use of the more perfect modern firearms. The surgeon is 
therefore justified in estimating the lesion in a given case to include 
the structures in the path of the bullet as determined by the location 
of the apertures. This statement contemplates due consideration 
of the position of the individual at the time of injury. 

The character of the lesion in the abdomen largely depends on the 
factors of velocity, sectional area and resistance on impact. The 
latter is especially variable in this anatomical region, depending as it 
does on the amount of fluid contained in the intestinal tube when hit. 
As already pointed out in preceding chapters, there are two things in 
the body which offer maximum resistance to the bullet, viz., compact 
bone and water. The degree of traumatism in muscle tissue at a 
5-foot range, for instance, for the present service rifle is not much 
beyond 17 mm. If, however, the ball should make an impact at the 
same range upon the intestine or stomach when these organs are loaded 
with fluid contents, the resistance encountered by the maximum 
velocity would result in extensive lacerations and shock, which would 
end in death at once or very soon thereafter. If the intestine is but 
partially loaded the lesion will be correspondingly less, and if it lies 
empty the amount of destruction will be no less than we find in other 
soft parts, like muscle tissue. In the case of the latter the amount of 
destructive effects would be measured more by the sectional area of 
the bullet. Wounds from a .45-caliber bullet as an example would be 
correspondingly more lacerated and contused than those from a .22- 
caliber Flobert rifle, or the projectile of the reduced-caliber rifle. 

The size and character of the wound in a hollow viscus is also 
influenced by the angle of impact. Wounds from shots transverse to 
the gut are smaller than those disposed in an oblique direction. The 
redundance of the mucous membrane over the serous coat also influ- 
ences the size of the opening and liability to escape of gas and fluid 



GUNSHOT WOUNDS OF THE ABDOMEN 257 

contents into the peritoneal cavity. Perforation of the small intestine 
is followed by eversion of the edge of the mucous coat and in small 
perforations like those of the .30-caliber military rifle, this occurrence 
may go far to explain the unexpected recoveries that have become so 
common in recent campaigns. This hernia which is said to be due 
to the redundance of the mucous coat and further to contraction of the 
circular muscular fibers is not so apt to occur in wounds of the stomach 
or colon. 

Wounds of the intestines per se are not prone to hemorrhage unless 
the lesion is located at the mesenteric border. On the other hand 
wounds of the mesentery proper, the omentum, and solid viscera are 
very apt to be followed by bleeding. The cutting effects of reduced- 
caliber jacketed bullets are specially exhibited in injury to vessels in 
the abdomen and doubtless this class of wounds figures quite a bit in 
swelling the mortality list on the field in the wars of to-day. Hemor- 
rhage on the whole is one of the most frequent causes of death in 
abdominal wounds. Its occurrence is aggravated by the engorgement 
of the internal organs when reaction from shock is about to take place. 

Extravasation from the stomach, the urinary and gall bladders 
has an important pathological significance. Wounds of the latter 
two are usually followed by discharge of their entire contents while 
a wound of the stomach is only accompanied by partial extravasation 
when the wound is sufficiently large. 

Extravasation takes place immediately when the wound is manipu- 
lated and if the opening happens to be large. Even in extensive 
wounds Douglas 1 states that extravasation occurs less frequently in 
the first few hours than is generally supposed. Eversion of the mucous 
membrane and arrest of peristalsis during the first twenty-four hours 
are chiefly concerned in preventing extravasation. Should peristalsis 
be resumed the mucous membrane is retracted, and if the exudate is 
insufficient extravasation takes place. 

Wounds of the mesentery find their chief pathologic interest when 
the projectile cuts a vessel. Hemorrhage threatening life at once, or 
gangrene later, is the chief danger. The latter is especially prone to 
occur in wounds at the mesenteric border. 

The facts to be remembered when in the presence of a gunshot 
wound of the abdomen are : 

(1) The outcome is problematical. 

(2) The exact lesion is uncertain. 
x Op. cit. 

17 



258 GUNSHOT WOUNDS 

(3) All wounds are septic from (a) the clothing, (b) skin, (c) the 
projectile and (d) extravasation when present. 

(4) Complications are uncertain. 

(5) When the abdominal cavity has been penetrated, visceral 
perforations are present in 97 per cent, of the cases. 

(6) A bullet crossing the intestinal area may do so without perfor- 
ating the gut, but the occurrence of perforations is the rule. As 
many as twenty-eight perforations have been recorded in one case. 
Multiple perforations occur mostly in the ileum from transverse and 
oblique shots disposed from flank to flank. 

The outcome will depend upon the nature of the injury, the 
amount of hemorrhage, the character of infection and the presence 
of extravasation from the intestinal tract, the biliary and urinary 
passages. A small hemorrhage may be absorbed, large hemor- 
rhages unless they prove immediately fatal are prone to undergo 
septic changes ending in peritonitis. Effused blood is at times walled 
off by plastic lymph and then absorbed, otherwise pus formation takes 
place. The development of perforation peritonitis in cases of intes- 
tinal perforation is the rule in the course of twelve to twenty-four 
hours. Virulent infections have been known to cause death before 
the appearance of the characteristic changes incident to peritonitis. 

General Symptoms. — Constitutional shock is the first symptom to 
attract attention. It is not always present, however, and it may be 
present in profound degree in cases where the peritoneum has not 
been involved, a fact which tends to lessen its importance as a symp- 
tom with diagnostic features. It is generally admitted that the 
importance of shock as a symptom rests on its duration. 

Vomiting is a pretty constant attendant symptom of penetrating 
wounds of the abdomen, but it may be due to shock as well. Vomit- 
ing of blood is indicative of gastric perforation but not necessarily 
so. It may occur from contusion. 

Pain at first of a colicky and griping nature about the region of 
the umbilicus is a fairly constant symptom of lesion of the small in- 
testine (Parker and Meyer). Later the pain radiates to the chest 
and groins and generally over the abdomen. 

Tympany occurring suddenly from escape of intestinal gases, 
sufficient to efface liver and splenic dullness, was evidently common 
with the use of larger-caliber bullets since Otis refers to it as one 
of the important symptoms. The use of smaller calibers and the sub- 
sequent hernia of the mucosa in the small opening has the tendency 



GUNSHOT WOUNDS OF THE ABDOMEN 259 

to prevent the escape of gas, since Treves and other observers in 
recent times lay no stress upon it as a sign of diagnostic value. It is 
a prominent symptom of intestinal perforation in later complications 
and perforations. 

Emphysema occuring in the cellular tissue about the wound is a 
rare symptom. It is not a definite sign of intestinal perforation 
although it does occur after wounds of the colon from colon bacillus 
infection. 

There are certain signs which are regarded as positive evidence 
of intestinal perforation: 

(1) Escape of intestinal gas, feces or intestinal worms from the 
wound of entrance or exit. 

(2) Protrusion of the injured gut at wound of entrance or exit. 

(3) Passage of the missile or blood by the anus. 

Escape of gas and feces and protrusion of the intestines were com- 
mon enough symptoms from wounds by the old armament and they 
are common with the use of present-day projectiles when the 
injury exhibits explosive effects or from wounds inflicted by shell frag- 
ments and shrapnel. Escape of intestinal worms is rare, except among 
peoples in tropical countries where intestinal parasites are to be found 
in the intestines of all natives. Four worms were found making their 
way in the peritoneal cavity in one of the author's cases in the Philip- 
pines fourteen hours after the injury, and the small intestines were 
everywhere inhabited by the ascaris lumbricoides. The great diffi- 
culty with the more certain signs of intestinal lesion lies in the fact 
that they are either absent or late in making their appearance. Pas- 
sage of red blood from the anus indicates lesion of the colon or rectum, 
but as already stated it is one of the later symptoms. Dark bloody 
stools indicate lesion of the small intestine. The discharge from the 
anus is in the form of a dark semifluid mass (melena), but it does 
not appear until re-establishment of peristalsis which occurs too late 
to make the symptom of diagnostic significance to the surgeon. 

Diagnosis of perforation has often to be inferred from a study of 
the location of the apertures made by the ball and the various anatomi- 
cal structures which normally lie in the bullet's path. In the days 
of low- velocity projectiles much was written of the erratic course of 
balls. It is said that missiles often took circuitous routes from the 
point of entry to the point of exit on impact against hard and soft 
tissues alike. Much of this sounds like fable now. As we understand 
the mechanics of projectiles to-day, we recognize no angles, nor devia- 



260 GUNSHOT WOUNDS 

tions to occur from the point of impact to that of exit. We regard 
the idea of a modern bullet deflected by the skin, fascia, or a knuckle 
of intestine as mythical. We figure that everything in the line of 
flight of a bullet is perforated and the surgeon who relies on this idea 
is seldom wrong. 

Doctor Senn once advocated the so-called hydrogen gas test to 
detect intestinal perforation, but this method in diagnosis is unreliable 
and it takes valuable time. 

The diagnosis of the exact lesion is not so important as the diagnosis 
of penetration of the peritoneal cavity itself, and that must be inferred 
from the position of the wounds and the direction in which the bullet 
was travelling at the moment of impact. Whether the small intestine 
is injured or whether it is the large intestine does not matter. It is 
all guess work at best until the abdomen is opened. The most that 
we can say is that wounds in the umbilical region are apt to be attended 
with lesion of the small intestine, wounds disposed transversely from 
flank to flank are apt to be complicated by lesion of the colon; those 
located above a line drawn across the umbilicus and below the costal 
margin are more often attended with lesion of the transverse colon 
and stomach, while wounds disposed obliquely may implicate large and 
small intestines and some of the solid viscera as well. Escape of hard 
fecal matter from the external wound suggests lesion of the large intes- 
tine and if the fecal matter be fluid the evidence points to lesion of the 
small intestine. Dark blood in the stools occurs with lesion of the 
small intestine, while red blood indicates lesion to the large gut. 

Prognosis and Fatality of Perforating Gunshot Wounds of the 
Abdomen. — The gravity of this class of wounds ranks with that of 
wounds of the head and spine. It was especially so with the use of the 
old armament. Penetrating and perforating wounds of the abdomen 
regardless of the viscera involved gave a mortality of 92.5 per cent, 
in the Crimean War; 90 per cent, in our great Civil War; 69 per cent, 
in the Franco-German War; an average of 67.1 per cent, in 115 
cases in the Spanish- American War and Philippine Insurrection; 
and approximately 56 per cent, for the Russian wounded in Manchuria. 

Shock from extensive lesion of the abdominal contents is a potent 
cause of death on the field. Impact at close range from the high- 
power military rifle bullet, especially when the digestive tube is filled 
with semifluid contents, causes wounds with explosive effects that 
prove rapidly fatal. The wounds which favor hemorrhage and shock 
seldom reach field or base hospitals, they are uniformly fatal in a 



GUNSHOT WOUNDS OF THE ABDOMEN 261 

very few hours, and they occur amid environments which preclude 
laparotomy. 

At the same time that the reduced-caliber bullet, impressed with 
maximum energy, proves so deadly as in the foregoing class of cases, 
there are other cases occurring at mid and more remote ranges which live 
to reach field hospitals with but few of the marked symptoms of per- 
foration. The large majority of these are followed later by the sudden 
development of fatal septic peritonitis. There is still another class 
in which the location of the wounds points strongly to the presence of 
visceral lesion, with but slight symptoms of perforation. These cases 
are apt to end in recovery and they form a surprising percentage of 
the cases in the field hospitals of recent wars. This was the class of 
cases that stood out as a puzzle to the surgeons of the 5th Army Corps 
at Santiago who were among the first to recognize the divergence that 
lies in the pathology, prognosis, and the necessity for surgical inter- 
ference, between cases of abdominal wounds in military and civil 
hospitals. 

TREATMENT OF PENETRATING AND PERFORATING GUN- 
SHOT WOUNDS OF THE ABDOMEN 

Whether the contained viscera have been perforated or not the 
treatment of gunshot wound of the abdomen at the onset is the same. 
This may be divided into general and operative measures. The gen- 
eral treatment consists in absolute rest on the back with shoulders 
raised and the knees flexed. The latter will materially add to the com- 
fort of the patient. Transport for any distance should be withheld. 
If necessary to remove the patient, even on a stretcher, this should 
be done with great care. The patient should himself remain absolutely 
passive in any effort to move him. All fluids, food or medicines per 
os should be interdicted for thirty-six to forty-eight hours. Thirst 
may be relieved by injections of warm water per rectum. Shock may 
be combated by strychnia hypodermically and stimulants per rectum. 
The external wounds should be dressed antiseptically. For cases 
occurring on the field painting the skin about the wound with tincture 
of iodine preceding the application of a first-aid dressing is preferable. 

When operation is not to be practised, opium should be admin- 
istered in the form of morphine hypodermically to control pain and 
peristalsis. In cases which lend a hope of recovery opium will form 
the sheet anchor of the treatment, and in those which appear hopeless 
it will ameliorate suffering. 



262 GUNSHOT WOUNDS 

The question of operation has received much attention in recent 
times especially from surgeons in civil practice. Since the great 
advances in abdominal surgery, the question of operation in military 
practice was never prominently brought to the attention of military 
surgeons until the Spanish-American and Anglo-Boer Wars. At the 
same time that it was the rule in civil hospitals to operate in all cases 
as early as possible, the U. S. Army surgeons were among the first to 
recognize that the rule of our civil confreres could not be followed in 
military practice and this view has since been accepted by military 
surgeons in all countries. Incidentally the failure of military surgeons 
to follow the lead of men in civil practice has enabled the profession 
to observe what may be the outcome in cases that are let alone, and as 
we hope to show later, the results in the practice of military surgeons 
in recent wars have had their influence in modifying the views of opera- 
tors in civil life. 

Surgeons in civil practice were and many are still of the opinion 
that early laparotomy with a view to exploration and the performance 
of such surgical attention as existing lesion might demand offer the 
best chance for recovery. Their conclusions were based upon statis- 
tics of non-operated cases in the pre-operative era which are quoted 
in all of the literature and which run about as follows: for every 100 
cases of gunshot perforation of the abdomen the intestines will be per- 
forated in 73.2 instances and death is the rule in all of these. Either the 
intestines or solid viscera or both will be injured in 97 per cent, of 
the cases and for these death is the rule in nearly every case in a few 
days or weeks, as a result of septic infection or abscess. If these sta- 
tistics are correct there is no doubt that surgeons of skill in abdominal 
work, under favorable environment were, and still are, justified in 
following the rule of an early operation in all cases. 

Doctor W. E. Parker 1 has shown that when cases are treated by 
laparotomy, those exhibiting wound of the solid viscera give a mor- 
tality of only 61.6 per cent., while in the class involving both solid and 
hollow viscera there is a mortality of 62 per. cent. Parker further shows 
that the mortality rate rises as the time of operation is delayed and 
that of the cases showing wound of the hollow viscera operated upon 
within the first seven hours the mortality falls as low as 47 per cent. 
The hope of recovery in those operated upon between seven and four- 
teen hours declines rapidly and all hope is practically lost after the 
lapse of twenty-four hours. 

1 Proceedings Southern Surgical and Gynecological Assoc, Vol. XI, 1896. 



GUNSHOT WOUNDS OF THE ABDOMEN 263 

Dr. Ernest Siegel 1 points out that the death rate in 532 non-operated 
cases was 55.2 per cent.; and 51.6 per cent, in 736 cases subjected to 
operation. This tabulation was made in 1898 for cases occurring from 
weapons used in civil life prior to that time. The results favor treat- 
ment by operation by the small margin of 3.6 per cent. For those 
operated upon within the first four hours the mortality is only 15.2 
per cent., while of those operated upon after twelve hours the mortality 
is 70 per cent. 

Fenner 2 gives a series of 105 cases with visceral perforation sub- 
jected to operation with a mortality of 73.95 per cent. 

Richard Douglas 3 collected 65 cases operated upon, in the literature 
between 1895 and 1900 not included in SiegeFs cases, with the surpris- 
ingly low mortality of 32.3 per cent. 

In the Spanish-American War we had surgeons of recognized 
ability from civil life who accompanied the army at the front. Among 
these were Professor Nicholas Senn of Chicago, with the rank of 
Lieutenant-Colonel of Volunteers, Major Charles Nancrede, U. S. 
Volunteers, Professor of Surgery in the University of Michigan, and 
Doctor W. E. Parker, Acting Assistant Surgeon, U. S. A., of New Or- 
leans, just referred to. Doctor Parker's impressions of gunshot 
wounds of the abdomen by the Spanish Mauser under the conditions 
that obtain in active campaign are set forth in a paper read before the 
Southern Surgical and Gynecological Association at its annual meeting 
1898-99. He mentions the three laparotomies which were done at 
the front with fatal results and cites cases in which he had the oppor- 
tunity to perform laparotomy himself and where he advised against 
operation because of "the small caliber of the bullet, the difficulty in 
getting hot water, and the absence of trained assistants. Then, too, 
it is a good deal of a question if, in the congested condition of an army 
hospital after a battle, we would be justified in taking the time neces- 
sary for such an operation to the detriment of other wounded men." 
In concluding this paper he advised against operative interference on 
the field except in the presence of internal hemorrhage. After Doctor 
Parker had read a paper at a previous meeting in 1896 on Penetrating 
Wounds of the Abdomen, before the same Society, a lengthy discussion 
took place on the management of gunshot wounds of the abdomen in 

1 Siegel, Beitrage zur klin. Chirurg., XXV, 1898. 

2 Fenner. Annals of Surgery, Vol. XXXV, 1902. 

3 Richard Douglas, Surg. Diseases of the Abdomen, Phila., Blakiston, 1909. 



264 GUNSHOT WOUNDS 

which some of the leading surgeons of this country took part. The 
views of the members were so generally unanimous in favor of early 
operation that the Association then and there adopted a resolution 
which proclaimed it to be the sense of the Southern Surgical and Gyneco- 
logical Association that in all cases of penetrating wounds of the abdo- 
men it became the duty of the attending surgeon to make an explora- 
tory incision and that when found necessary the repair of existing 
lesions should be practised. This was the doctrine advocated prior 
to the Spanish-American War by surgeons in civil life generally. 
Naturally when Doctor Parker read his second paper, after the battle 
of Santiago, in which he advocated "that abdominal work should not 
be attempted in the field unless there are symptoms of hemorrhage/ ' 
some of his confreres thought that he had receded from his position of 
three years before, but in the discussion which followed the reading 
of this paper, he took occasion again to express his former convictions 
on the value of early operation in civil hospitals in which he stated 
that laparotomy was the first thing to do. 

The hesitancy which Doctor Parker and all our surgeons expressed 
at the battle of Santiago toward laparotomy has been voiced by 
surgeons in recent wars generally. Treves, MacCormack, Watson 
Cheyne, Makins and Stevenson in the Anglo-Boer War admit the 
value of the rule to open the abdomen early in civil practice, but they 
are unanimous in advising against operation in active campaign because 
of the want of trained assistants and the unfavorable conditions that 
obtain to properly secure aseptic work, and because so many of the 
cases get well without operation. 

Mr. Makins, writing from the standpoint of a civil surgeon upon 
cases in which penetration had occurred in the central area around the 
umbilicus in the South African campaign, states as follows: "The 
surgeon will often find himself surrounded by difficulties, so hand- 
tied by the overcrowded state of the field hospital and want of all but 
the most inadequate means of even aseptic work, that he may feel 
himself compelled to refrain from interfering, while he knows that 
under other circumstances operation might give the patient a chance 
of life." 

As to the experience of army surgeons in the Russo-Japanese War, 
they took the field fully advised of the untoward experience of the 
American and English surgeons. Nevertheless, the reports show that 
on both sides, the Russian and Japanese surgeons did laparotomies in 
the beginning of the campaign. Major Charles Lynch, Medical Corps, 



GUNSHOT WOUNDS OF THE ABDOMEN 265 

U. S. A., 1 our attache with the Japanese army, states that abdominal 
wounds were universally treated on the expectant plan by the Japanese 
surgeons, and speaking of field environments he says "it would have 
been absolutely unjustifiable, however, for either the Russian or Japa- 
nese to have operated with the conditions as they existed." In the 
early part of the war he saw laparotomies performed but the results 
were so discouraging that the operating surgeons had to desist in the 
same way that some of our operators were commanded to desist from 
operative interference on the line at Santiago. 

Follenfant, a French Medical Officer with the Russian army saw 
some successful laparotomies performed in a specially prepared operat- 
ing room on a hospital train inside of three hours after the injury, 
otherwise the success attained in primary laparotomies was bad. He 
states that in the hospitals at the rear, partial laparotomies for the 
evacuation of abscesses consequent upon localized peritonitis were 
frequently performed with success. To us this is additional evidence 
of the number of cases of gunshot wound of the abdomen by the new 
military rifle that recover without fatal septic peritonitis. As a matter 
of fact Follenfant was strongly impressed by the beneficence which 
resulted from the use of small-caliber bullets in this war. He saw men 
who were cured and restored to duty after apparent gunshot lesion of 
the intestine, without operation. But he adds that penetrating 
gun-shot wounds of the abdomen by shrapnel balls were generally 
fatal. 

Another of our attaches, Col. Valery Havard, Medical Corps, 
U. S. A., 2 saw twenty-five cases of gunshot injury of the abdominal 
cavity. "No operation was possible or attempted." Some of the 
wounded had been transported forty miles in carts over rough roads, 
and also on horseback. Seven died. Eight developed peritonitis. 
These happy results were no doubt obtained from the slightly wounded 
— cases in which the viscera were but slightly injured, where the hollow 
viscera were probably not perforated and if perforated the nar- 
row perforation was more than likely occluded by hernia of the 
mucosa. 

The cases reported by Bornhaupt, 3 who was attached to a Red 
Cross Hospital on the Russian side in the Manchurian campaign, give 

1 War Department, Office General Staff, No. 8, Jan. 1, 1907. 

2 War Dept. Report Gen'l Staff, No. 3, Oct. 1, 1906. 

3 L. Bornhaupt. Bauchschuesse im russisch-japanischen Kriege. Archiv fur 
klinische Chir., 1907, LXXXIV. 



266 GUNSHOT WOUNDS 

further evidence of the beneficence which results from gunshot wounds 
of the abdomen by reduced calibers. It should be remembered that the 
bullet of the Japanese was the smallest in caliber of the modern military 
rifle projectiles, being 6.5 mm. weighing about 157 grains. He states 
that out of all penetrating shot wounds that came to hospital for treat- 
ment 89.9 per cent, were inflicted by the jacketed rifle bullet. Out 
of 162 penetrating wounds of the abdomen three were caused by 
bayonet thrusts, sixteen by shrapnel and 143 by jacketed bullets. 

Those who were received for treatment were shot generally six 
or eight days before, only a few receiving more than first-aid treatment 
on the hospital trains to Karbine. Out of 162 cases, 138 showed 
both wounds of entrance and exit; in twenty-four or fourteen per cent, 
the bullet lodged; in three instances the patients received two pene- 
trating wounds of the abdomen. He divides the 162 cases into four 
groups of which the first three required no operation, the treatment 
was expectant. The fourth group required operation. 

In eighty-nine cases of the first three groups there were no symp- 
toms. Out of 115 cases treated conservatively but three died giving 
a mortality of 2 . 6 per cent. 

The symptoms in the early part of the history of the cases were 
gathered from statements of the patients themselves. Some showed 
signs of peritoneal irritation — pains in the abdomen, vomiting and tym- 
panites. After five or six days all these symptoms disappeared. Most 
of them walked from 2 to 5 miles to the dressing station where a first- 
aid dressing was applied; some were carried by comrades and some 
rode on horseback. 

In four of the cases the shots were delivered at very close range, 
while the remainder received the wounds at 30, 40, 50, 200 and 1600 
yards. Some of the shots ran transversely, obliquely and antero- 
posteriorly through the intestinal area. 

In all great battles there are no doubt, with the use of the present 
armament, a certain number of abdominal wounds destined for a 
favorable outcome, in the same way that a larger number are doomed 
to die from the beginning. The worst of these die soon after they are 
shot. The wounds received in the explosive zone belong to this class. 
Col. J. Van R. Hoff, Medical Corps, U. S. Army, 1 reports that at short 
range the reduced-caliber bullet of the Japanese when striking the full 
stomach caused great laceration and bursting of the organ from 

1 War Dept. Report Gen'l. Staff, No. 3, Oct. 1, 1906. 



GUNSHOT WOUNDS OF THE ABDOMEN 267 

surrounding attachments. Like results were observed with a full 
bladder, and the solid organs. In these cases death ensues very early 
from shock and hemorrhage. Hoff testifies to the fatality attending 
abdominal wounds from ricochet rifle bullets, also from shrapnel 
balls, and shell fragments. 

Captain Eugenio de Sarlo 1 from the recent Italo-Turkish war in 
North Africa states that laparotomy in the field should be limited to 
the utmost — to cases in which fatal hemorrhage is taking place. Aside 
from the fact that laparotomies were generally attended with fatal 
results, too many wounded required the precious time that must be 
devoted to the comparatively few who were hit in the abdomen. In- 
stead of laparotomy the Italian surgeons employed hypodermoclysis, 
subcutaneous injections of morphine, ice bags to the abdomen and the 
interdiction of food for several days. This treatment gave 55 per cent, 
of cures according to the reporter and the happy outcome is attrib- 
uted to the adhesive property of the peritoneum which tends to 
circumscribe the part injured, and to the defensive action of the 
omentum, and closing of the small orifice as a result of hernia of the 
mucosa. 

We believe we have written enough upon gunshot wounds of the 
abdomen in battle to show that there are many among the wounded 
who recover, and more who die. The former seem surprisingly large 
because of the large number of wounds which come under the notice of 
the surgeons at one time, and the statistics of recoveries seem to be 
especially good because they are gathered from the less serious cases and 
as already stated because many of the favorable cases result from the use 
of small bore rifle bullets at ranges beyond the zone of explosive effects. 

From the foregoing it appears that the rule in civil practice has been 
to operate on all cases of penetrating and perforating gunshot wound 
of the abdomen, and in military practice in active campaign the rule 
is to operate only on cases exhibiting symptoms of internal hemor- 
rhage. So far as the practice in active campaign is concerned the rule 
will have to stand until we can change the unfavorable environments, 
a thing hardly possible. 

As to the rule to be followed in civil practice this, as we have 
already shown, was based upon statistics of operated and non-operated 
cases, and the latter made such a poor showing that laparotomy under 

1 Notes on Wounded at Derna, by Captain de Sarlo. Caducee, Nov. 16, 1912. 
Rev. by Ed. Laval. 



268 GUNSHOT WOUNDS 

favorable conditions was established with apparent reason. In the 
earlier history of the operative treatment the showing was far more 
favorable to operation than it has become in recent years. As we 
have already stated the results of the laissez-faire treatment of the 
military surgeon have awakened the attention of surgeons in civil prac- 
tice. They are now revising their later statistics and a study of these 
make it a question if operation in all cases is the proper rule to follow. 
In approaching this subject of the treatment to be adhered to in civil 
hospitals we have to remind our civil confreres that military statistics 
for their purpose are very much one-sided. We only take cognizance 
of the cases which reach hospital care and they are those for the most 
part that have survived a number of hours already — they are the cases 
which have survived shock more or less and that have not died of 
internal hemorrhage. If our statistics were made up from all the 
cases as they are in civil life, and if these cases were all operated upon 
as they generally are in civil hospitals, the percentage of mortality 
of our operated cases would be enormous, because the character of the 
wounds in those that die soon after they are hit by rifle bullets — in the 
explosive zone — and from pieces of shells and shrapnel balls, are doomed 
to die under any method of treatment. 

We have collected the results in 144 cases of penetrating gunshot 
wounds of the abdomen from the Annual Reports of the Surgeon 
General, U. S. A., from 1898 to 1910 inclusive. Of this number fifty- 
eight cases were treated by laparotomy with a mortality of 67 per 
cent.; and eighty-six cases were treated expectantly with a mortality 
of seventy per cent. Doubtless many of the cases treated expectantly 
were so treated on account of the gravity of the injuries or because of 
the unfavorable surroundings for operation. 

Twenty-nine of the laparotomies were reported for the years 1898 
to 1902 which corresponds to the years of active field operations 
during the Spanish- American War and Philippine Insurrection. The 
cases were operated upon no doubt mostly under the unfavorable 
conditions that obtain in war. The mortality for this group is 71 
per cent. The remaining twenty-nine laparotomies were done between 
the years 1903 and 1910, which corresponds to garrison conditions in 
which the surgeons have access to fixed hospital accommodations and 
for this group the mortality is 62 per cent. Compared to results which 
we will show later, these results are in keeping with those in other armies 
for field conditions, and the garrison cases compare favorably with 
those in some of our large civil hospitals. 



GUNSHOT WOUNDS OF THE ABDOMEN 269 

The missiles inflicting the wounds in the 144 cases are not suffi- 
ciently well designated to give any idea of their caliber or composition. 
One hundred and twenty of the wounds were inflicted by bullets,^ two by 
shells, three by shrapnel, one by lantaca slug, and eighteen not stated. 
We may take for granted that the majority of the wounds caused by 
bullets resulted from steel-jacketed reduced-caliber bullets. Quite a 
number were inflicted by .38-caliber brass-jacketed Remington rifle 
bullets. Beyond that, the nature of the projectiles cannot be defi- 
nitely stated, which gives an indefinite idea of the nature of the 
wounds. In reporting gunshot injuries practitioners should be more 
specific in describing the nature of the projectiles. This is a fault 
common to both military and civil practitioners. Surgeons generally 
should be impressed with the fact that there are gunshot wounds and 
gunshot wounds; that the character of the lesion in a given case and 
the prognosis thereof is largely influenced by the velocity and the sec- 
tional area normally present in the projectile, and what may be ac- 
quired by deformation. 

Later statistics from civil hospitals and individual practitioners 
tend to show that a series of non-operated cases nowadays does better 
than those with operation. Dr. Rudolph Matas of New Orleans was 
kind enough to look over the statistics of Charity Hospital in that city, 
where so many cases of gunshot wounds are treated annually. He 
informs us that according to Doctor T. G. Richardson in the five years 
preceding May, 1887, in the time when operative treatment was not 
employed, the mortality for non-operated cases of penetrating gun- 
shot wound of the abdomen was 59.4 per cent. This can be taken as a 
basis for the chance of recovery by the expectant plan of treatment 
from gunshot of this region by projectiles from pistols and revolvers 
of low velocity and moderate calibers so much used in civil life at 
about this time. 

The first group of cases operated upon at this hospital was by Doc- 
tor A. B. Miles, who reported thirteen cases in 1893, with a mortality 
of 60 per cent. The percentage of recoveries was 40 per cent., which is 
practically the same as in those not operated and reported by Richard- 
son, viz., 40.6 per cent. 

Later, in 1896, Doctor W. E. Parker, assistant surgeon of the hospi- 
tal, operated thirteen times with 53.8 per cent, mortality, 46.2 per cent, 
recoveries. 

Later, Matas and Hynes (not published) compiled all cases for the 
decade 1890-1900 treated by the surgeons of Charity Hospital: 



270 



GUNSHOT WOUNDS 





Cases 


Deaths 


Mortality 


Operated 

Non-operated 

Total 


122 
112 

234 


84 

60 

144 


68.85 per cent. 
53.57 per cent. 
61.5 per cent. 



which makes the expectant and conservative mode of treatment more 
favorable by 15 per cent. 

For the same hospital Dr. E. D. Fenner (Annals of Surgery, Vol. 
XXXV, 1902, page 15) compiled 113 cases of penetrating gunshots 
of the abdomen treated by laparotomy with a mortality of 69 per cent. 
The mortality was still larger, 73.95 per cent, in cases that were compli- 
cated by visceral injury. 

In 1905 Dr. H. R. Shands, resident interne of the hospital, wrote a 
thesis which deals with some of the statistics of the hospital as follows: 
150 penetrating wounds of the abdomen were treated in the hospital 
for the four years Jan., 1901, to Jan., 1905. 



Gunshot wounds 



Abdomen 



Deaths 



Mortality 



Perforating . . . 

Operated 

Non-operated 



US 
59 
59 



81 
46 
34 



68 . 7 per cent. 
77 . 9 per cent. 
57.6 per cent. 



(73.7 per cent, of these gunshot wounds occurred in negroes.) 

The injury sustained by the various organs was ascertained in fifty- 
four of the fifty-nine cases as follows: Intestines were wounded in 
79.6 per cent. The stomach in 22.2 per cent. The bladder 13 per 
cent. The kidney in 3.7 per cent. The spleen in 1.8 per cent. The 
liver in 5.5 per cent. Perforations of the intestines ranged from one to 
nineteen in number, and those of the stomach ranged from one to 
four in number. 

In 339 cases of penetrating gunshot wounds of the abdomen com- 
piled by Doctor C. W. Allen for the years 1899 to 1908 inclusive, 1 there 
were 221 deaths or a mortality of 64.7 per cent. In this series, the 

1 New Orleans Med. and Surg. Jour., Sept., 1911. 



GUNSHOT WOUNDS OF THE ABDOMEN 



271 



operated and non-operated cases are included together, and the mor- 
tality given is regardless of the plan of treatment followed. 

The last series noted is 185 cases for the years 1908 to 1911 inclu- 
sive with a mortality of 113 or an average mortality of 60 per cent. 
As in the preceding series no attempt was made to separate the oper- 
ated from the non-operated cases. 

Doctor Matas who has been connected with this great hospital 
for many years states that " since 1905 the operative treatment seems 
to grow less and less in favor in the estimation of the house officers, 
and the mortality as exhibited in the last five annual reports is practic- 
ally the mortality of the expectant or non-operative treatment," This 
average mortality of 60 per cent, for the five years mentioned is almost 
the same as the mortality which Richardson found for the five years 
preceding 1887, viz., 59.4 per cent., and which was adopted as an aver- 
age mortality for non-operated cases. This is certainly far better 
than the average mortality for the group of operated cases as shown 
in the following recapitulation: 





Operated cases 


Deaths 


Mortality 


Matas and Hynes, 1890- 

1900. 
Dr. H. R. Shands, 1901- 

1905. 


122 

59 


84 
46 


68 . 85 per cent. 
77.9 percent. 


Total 


181 


130 


average 71.8 percent. 



These results, for the operative treatment, certainly form a wide de- 
parture from those attained by Dr. W. E. Parker, who was himself a 
resident interne in Charity Hospital, and who, as already stated on 
page 243, showed that in the operated cases within the first seven hours 
of perforating gunshot wounds of the hollow viscera, the mortality 
was brought as low as 47 per cent. Parker's results are better than 
Siegel's series, which gave a fatality of 51.6 per cent.; not so good as 
the latter's cases operated upon within four hours, which was 15.2 per 
cent., nor Richard Douglas' results which gave a mortality of 32.3 per 
cent, for all cases. 

The figures above quoted for Charity Hospital lead one to believe 
that the results in gunshot wounds under the operative mode of treat- 



272 



GUNSHOT WOUNDS 



ment are worse than formerly. Taking this for granted, what reason 
can we give to explain the change. 

1. Is it due, as some have suggested, to the fact that the lapa- 
rotomies which were once undertaken by surgeons of mature judg- 
ment and prolonged experience in abdominal work are now performed 
by the house staff, young men, who have no personal experience, and less 
dexterity, to do an operation with the necessary perfection and rapidity 
that this, the greatest of all emergency operations known to surgery, 
requires? or 

2. Is it due to a change in the lesion of gunshot wounds to-day as 
compared to the lesion of twenty or more years ago. 

The first of these questions can be answered by the visiting staff 
of the hospitals concerned, and in order to find an answer to the second 
question, we know that the change in the character of gunshot wounds 
in civil practice has been coincident with the evolution in firearms, the 
same as in military practice. 

During the earlier use of firearms in civil life the projectiles from 
pistols and rifles were round, of large calibers and low velocities. Later 
conoidal bullets were used, when there was marked reduction in the cali- 
ber and weight of projectiles with some addition to the velocity. The 
crashing effects of conoidal bullets over those of the low-velocity spheri- 
cal balls is well remembered by surgeons still living. At this stage in 
the evolution of firearms there came a tendency to retain the smaller 
calibers with no marked tendency to increase the velocity of projectiles. 
This was a time in the evolution of firearms that just preceded the use 
of the high explosives. Bullets from pistols and revolvers of that day 
— about two decades and more ago — caused wounds the size of their 
sectional areas with an amount of destruction proportional to the range. 
The velocity was low compared to that impressed on the bullets of to- 
day, and there was a great tendency for projectiles to lodge. There 
were then many patterns of pistols and revolvers in the market, of 
small calibers, ranging from .22, .32, to .38 calibers, from which wounds 
were inflicted in personal combat. These weapons were very much 
used about the time surgeons first commenced to perform laparotomy 
as a measure of treatment in gunshot wounds of the abdomen. The 
lesions which they inflicted were not attended with much laceration and 
contusion. The favorable results in the operated cases were marked, 
and they attracted the attention of surgeons generally. It then be- 
came the fashion to open the abdomen in all cases wherever surgeons 
could master the environments, for exploratory purposes at least. This 



GUNSHOT WOUNDS OF THE ABDOMEN 273 

was the status of the subject at the time that the high-power explosives 
came into use. In Chapter No. 1, on Firearms, Explosives, Pro- 
jectiles and the Ballistics of the latter, as well as in the Characteristic 
Features of Gunshot Wounds as detailed in Chapter II, we have sought 
to show the changes in wounds from one period to the next. 

The introduction of nitrocellulose compounds has conferred marked 
velocity on lead projectiles of the pistol class, and now that the pro- 
jectiles for these weapons are enveloped in a jacket of hard steel, as in 
the so-called automatic pistols, the velocities have become doubled and 
trebled for this class of hand weapons, with no tendency in the reduc- 
tion of caliber. 

As we have aleady stated in Chapter II, under Wounds caused by 
Pistols and Revolvers, the effect of this additional velocity on the 
short, already unstable bullet, has been to render it more so. The 
projectile loses its balance when encountering the least resistance. It 
then travels at a tangent to its line of flight, or turns end over end, 
and, making an irregular impact, it lacerates and mutilates tissues, in- 
flicting conditions most favorable to the development of existing in- 
fection. In such a case laparotomy cannot remedy the damage done 
in the way of hematomata and contusion about the bullet's channel, 
and the patient is doomed to a fatal issue from the beginning. The 
instability of the bullet as just mentioned may be likened to the in- 
stability that has recently been conferred on the latest projectile of the 
reduced caliber rifle — the bullet S of some authors, the one recently 
adopted by this country, England and Germany and described on page 
57. We in the military service will witness the same changes in gun- 
shot wounds of the abdomen that the surgeons in civil life are witnessing 
from automatic pistols and revolvers now. We predict that no ob- 
server will ever again say, as Follenfant has said, of the wounds by 
the .25.5 Japanese rifle, "that the beneficence from the use of reduced 
calibers in war has even extended to gunshot injuries of the abdomen." 

In the recent Turko-Balkan War Major P. C. Fauntleroy, 1 M. C, 
TJ. S. A., reports that among the Bulgarian soldiers the large majority 
of the abdominal wounds died on the field or in a few days from 
septic peritonitis. The very few that reached the base hospitals only 
occasionally required laparotomy for intra-peritoneal abscess. Lejars 2 , 
Laurent, 3 and nearly all the medical observers in the Turko-Balkan 

1 Op. cit. 

2 Chirurgie d'Urgence — La Semaine Medicale, No. 28, July 9, 1913, by Dr. 

F. Lejars, Paris. 

3 Onze Mois de Chirurgie de Guerre, O. Laurent, Brussels. 
18 



274 GUNSHOT WOUNDS 

War have remarked upon the comparatively few serious wounds 
of the abdomen encountered in the field hospitals, which was pre- 
sumably due to the fatality of this class of wounds on the field of 
battle. The Turkish army was armed with the German Mauser of 
reduced caliber, firing the spitz bullet which corresponds to our 
pointed bullet. Notwithstanding the fact that the Turko-Balkan War 
referred to was fought with more field artillery, and the proportion of 
fatal wounds by shrapnel is larger than noted in any previous war, 
we have reason to believe that the spitz bullet has helped materially 
to swell the mortality among those hit in the abdomen. Between the 
deadly body wounds of the shrapnel ball and the mutilating effects 
of the pointed bullet of the military rifle, the future of laparotomy in 
field surgery is less promising than ever. 

The value of early operation has received approval from many 
quarters in the present World War. In the Congress of Military 
Surgeons at Brussels, April, 1915, Korte, Schmieden, Kraske, Rehn, 
Sauerbruch and Hanken all advocated early operation within the first 
12 hours. Kraske reports that out of 14 cases recently operated upon 
there were 6 recoveries, and it is his belief that all cases of intestinal 
injury die if not treated by operation. Sauerbruch operated on 54 
cases, with 23 recoveries. 

Enderlen and Sauerbruch advocated early operation. In 227 cases 
operated upon, 211 showed intestinal injury. In 52 cases of intestinal 
wounds treated conservatively, 46 died in the field hospital, 3 died later, 
and but 4 made complete recoveries. Of the 211 cases operated upon 
for intestinal lesion the mortality was 44.4 per cent. A mistaken 
diagnosis occurred eight times; none of the patients were injured by 
operation. The patients were generally kept quiet four weeks before 
transportation was undertaken. 

Tuffier, in his observations during the first five months of the war, 
states that a number of his confreres have reached the conclusion that 
some of the abdominal wounds heal spontaneously even with a 
stercoraceous fistula and they are generally wounds of the large intes- 
tine. Hemoperitoneum heals after incision or laparotomy, but more 
often spontaneously. Commenting on the value of laparotomy for 
wounds of the small intestine, he states that there then existed not 
more than twenty cures in the French army. This was at a time when 
the transportation facilities were not the best. He states that wounds 
of the liver and spleen are complicated by hemoperitoneum which may 
recover. Wounds of the gall-bladder are followed by fistula, which is 
spontaneously curable. 



GUNSHOT WOUNDS OF THE ABDOMEN 275 

Bouvier and Caudrelier in the Bull, et mem. soc de chir. de Paris, 
1915, XLI, 1257, report 33 cases of laparotomy for gunshot wound with 
18 deaths and 15 recoveries, a mortality of 54.5 per cent. The mor- 
tality for injuries of the small intestine was 66 per cent, and 40 per 
cent, in injuries of the large gut. They were only a few meters from 
the front with a fairly good equipment, and they operated on all cases, 
no matter how severe the injury or the condition of shock the patient 
was in at the time. Sometimes they operated by merely enlarging the 
existing wound, but most generally they operated through a median 
incision. In extensive wounds in which evisceration of the intestine 
was present they sutured or resected the protruded gut before opening 
the abdomen. Perforations were closed by suture, and in cases of 
multiple perforation in a short segment, resection was employed. 
Economy in time was practised in all cases. 

Quenu took part in the discussion and gave the results of Sencert 
who believes in the expectant plan of treatment, and by comparing 
the results of Bouvier and Caudrelier with those of Sencert, he 
deduces from them an argument in favor of early operation. Sencert 
treated 58 cases with only 13 recoveries which gave a mortality of 
77.5 per cent., as compared to 54.5 per cent, in the cases of Bouvier 
and Caudrelier. 

The authors believe that the indications for operation depend more 
on the time the surgeon gets hold of the cases than on the site of the 
operation. Patients should be operated upon as near the point of 
injury as possible — in 15 to 20 kilometers. Operated cases have been 
removed too early since many died as a result of transport. Quenu be- 
lieves they should be moved by stages, travelling a few hours at a time, 
preferably by automobile and resting for some days between stages. 

Another of the valuable contributions on the early treatment of 
gunshot wounds of the abdomen in the present war has issued from the 
pen of C. Wallace in the Lancet, London, II, 1336, 1915. In try- 
ing to arrive at the relative frequency of abdominal wounds the 
following data were obtained in a certain number of casualty clearing 
stations : 

1. 1.88 per cent, of all wounds. 

2. 1.5 per cent, of all wounds. 

3. 0.75 per cent, of all wounds. 

4. 0.62 per cent, of all wounds. 

The statistics from 9 field ambulances and 7 casualty clearing 
stations for a period of six months showed the following results: Per- 



276 GUNSHOT WOUNDS 

centage of abdominal wounds to total wounds, field ambulances, 1.92 
per cent, casualty clearing stations, 0.72 per cent. The difference is 
attributed to the greater mortality in field ambulances. 

In 1,098 abdominal wounds in 9 field ambulances during a period 
of six months the mortality was 30.33 per cent. In 131 cases of per- 
forating abdominal wounds in the same period from 6 casualty clearing 
stations the mortality was 58.49 per cent. 

As to the influence of position of the wound and direction of the 
missile on the probable nature of the injury, it is noted that in the region 
above the pyloric plane are found the least serious among abdominal 
wounds. Side-to-side wounds, especially if they are located far back, 
are very serious. Vertical wounds, from above downward, are also 
serious. 

Midline antero-posterior wounds are seldom seen, due to the vena 
cava and aorta occupying this line, wounding of which causes im- 
mediate death. The liver is most apt to be hit on the right side of 
this line, and the stomach occupies the space on the left side. Stomach 
wounds usually occupy both surfaces of the organ. 

On the right side the liver will be hit; the cardia and greater curva- 
ture of the stomach will be perforated on the left side. The kidneys 
will be perforated by shots traversing the lateral lines of the body in- 
cluding the spleen and splenic flexure on the left side. Uncompli- 
cated liver and stomach wounds are as favorable as similar wounds in 
the epigastric region. 

Oblique epigastric and hypochondriac wounds are necessarily more 
serious and they become more so as they become more oblique. The 
character of the liver wounds in these shots is marked by greater 
laceration and greater tendency to hemorrhage, and the stomach 
wounds are marked by a long slit or double opening when the axis 
of the flight of the bullet becomes parallel to the anterior wall, in which 
case extravasation is prone to occur. The liver and stomach wounds 
are apt to be complicated by spleen, kidney, and splenic flexure 
involvement. 

Vertical epigastric or hypochondriac wounds are nearly all inclined 
downward and inward, though they may be almost vertical, the en- 
trance and exit wounds being located on the front of the body. In 
such cases the wounds of the liver and stomach are complicated by 
involvement of the colon or small intestine. Vertical wounds on the 
lateral surface appear as thoracic wounds when they show no exit 
wounds. Those on the right side are not so dangerous since they 
only traverse liver substance; those on the left are more dangerous as 



GUNSHOT WOUNDS OF THE ABDOMEN 277 

they are apt to implicate the spleen, stomach, or colon. These at 
first point entirely to thoracic injury. 

Posterior and lateral wounds of the hypochondriac region are apt 
to be single entry wounds. Those from side to side are seldom seen, 
owing to their great fatality. They involve the liver, spleen, stomach, 
pancreas, and even the great vessels. 

Wounds between the axillary lines often exhibit omentum pro- 
truded through the ribs. They are more serious on the left side from 
the spleen, kidney, and splenic flexure involvement. These wounds 
are often caused by shrapnel or shell fragments. Access to this region 
is not easy; the wounds are therefore difficult and unsatisfactory to 
treat. 

Wounds between the transpyloric and intertubercular planes are 
very serious. Above the umbilicus they are like those above the trans- 
pyloric plane, and below the umbilicus the small intestine is involved. 

Antero-posterior shots in the midline are seldom met with. On 
either side, in the upper part of this region the colon is involved and 
injuries to it are easily dealt with. Lower down, near the midline, 
the wounds are grave as they involve the small intestine. Toward the 
sides in the lumbar regions, we find wounds of the ascending or descend- 
ing colon. If the peritoneal surface alone is involved the danger 
is not so great unless the wound in the wall is large. Wounds in the 
left lumbar region are very much more dangerous as the coils of 
jejunum overlie the great bowel. In flank wounds the colon and 
peritoneum may both escape owing to the thickness of the abdominal 
wall. 

Wounds entering the back in this region are apt to plough up the 
retroperitoneal tissue by mechanical violence or by subsequent hema- 
toma, and they are consequently more fatal than antero-posterior 
wounds. Single entry wounds of the loin often injure the retroperi- 
toneal tissue and pass into the colon. Shell fragments and wounds in 
this location are grave; they cause a large opening with escape of 
feces but free drainage and the fact that the traumatism is in plain 
view assists in the steps to be taken. This is seldom the case in wounds 
caused by smaller projectiles where leaks in the retroperitoneal tissue 
may occur which may cause death before sufficient drainage is 
provided. 

Side-to-side wounds are very fatal. If the small and large intes- 
tines are both involved, the spine or great vessels are injured since the 
vertical colons are set well back. For this reason side-to-side wounds 
which involve the small intestine alone seldom include the colon. 



278 GUNSHOT WOUNDS 

The amount of damage done varies. In some cases the gut is lacerated 
and cut across, the transverse colon and central portion of the stomach 
may be all but completely cut by one bullet. There may be only clean 
cut perforations or the peritoneum only may be penetrated. 

All wounds below the intertubercular plane are very serious. They 
include shots through the hips, thighs, and buttocks. 

Antero-posterior wounds in the hypogastric region are very serious, 
especially when compared to antero-posterior shots in the epigastric 
region. Midline wounds are fairly frequent; the bladder is not often 
implicated unless it is full at the time of injury; the pelvic colon and 
rectum may be involved. 

In the iliac regions the iliac colon and cecum may be implicated. 

Side-to-side wounds are very serious. Small intestinal wounds 
are nearly always multiple, the bladder and rectum wounds may be 
intra- and extra-peritoneal. 

In vertical wounds the wound of entry is often through the buttock, 
peritoneum, or thigh, and the iliac vessels may be involved. The 
peritoneal wounds are often overlooked, but pain in the abdomen is 
often present and should lead to suspicion of internal injury. The 
fatality in these cases is due mostly to hemorrhage from the iliac 
vessels and the fact that peritoneal wounds are often overlooked. 
Wounds of the rectum are quickly fatal from peritonitis. 

The possibility of a bullet traversing the peritoneal cavity without 
injury to the viscera is discussed in an interesting way. The author 
gives a chart which shows a number of cases in which the abdomen 
was opened for exploratory laparotomy and in which no hollow viscera 
were opened although the entrance and exit wounds clearly pointed to 
such an injury. In these operations tears of the peritoneal coats of 
the hollow viscera, stomach, or intestine, were not infrequently seen, 
a fact which would indicate that even a modern bullet can push aside 
the visceral wall without perforating it. Such cases are believed to 
account in a certain proportion of cases for complications like fecal 
fistula and intraperitoneal abscess. 

Determination of peritoneal involvement to make sure that the 
wound is penetrating is frequently difficult. This is especially true 
when there is no wound of exit. Symptoms of shock, hemorrhage, 
rigidity, peritonitis, and rapid pulse point to penetration, but these are 
not always present. 

Below the transpyloric plane with entrance wound on the right of the 
midline and the exit wound anterior to the right lateral line of the body 
is apt to be non-penetrating. On the other hand above the trans- 



GUNSHOT WOUNDS OF THE ABDOMEN 279 

pyloric line such a wound is almost sure to be penetrating. In the 
longitudinal direction an entrance wound near the costal margin with 
an exit wound above the groin points to penetration. 

In the case of single entry wounds the symptoms alone indicate 
penetration or non-existence of peritoneal involvement. 

A vertical wound entering from the thorax may give no sign for 
some time. A vertical wound entering from the buttock is apt to be 
attended with pain at the time of injury. 

Absence of liver dullness is no criterion of visceral penetration. 
Abdominal injury from a bomb explosion which exhibits multiple 
small wounds may be attended with doubt as to the existence of pene- 
tration. Rather than explore one or two of these wounds for the pur- 
pose of diagnosis it is best to make an abdominal incision, and to be 
guided in accordance with the findings. The author has found as 
many as 14 perforations in the small gut from small fragments issuing 
from one bomb. 

Symptoms of peritoneal involvement are generally: (1) rigidity of 
the belly wall; (2) rapid pulse; (3) indications of hemorrhage; and (4) 
absence of liver dullness. 

Rigidity is seldom absent after 4 to 5 hours; the same is true of 
the rise in pulse-rate. Local trauma without penetration may show 
rigidity but the pulse-rate may not rise. 

Symptoms of hemorrhage are hard to distinguish from shock. 
There is blanching and rapid pulse in both. In the case of hemorrhage 
restlessness is seldom seen. The same is true of air hunger and failure 
of sight. The amount of hemorrhage is generally very great before 
dullness can be of significance as a symptom. 

Retroperitoneal hemorrhage causes decided abdominal rigidity and 
well-marked shock. 

The effect that shock, hemorrhage, peritonitis, and septic infection 
of the retroperitoneal tissue have in causing death is shown as follows : 

1. The amount of shock is usually severe and it may be absent or 
nearly so for a number of hours. What actually causes shock is un- 
decided. Usually it is proportional to the extent of the injury; but 
profound shock may be present with a limited lesion or may be nearly 
absent in an extensive one. 

2. Hemorrhage is probably the most frequent cause of death. Its 
source is from (1) great vessels, (2) the mesentery, (3) the omentum, 
(4) the abdominal wall and retroperitoneal tissue, and (5) the solid 
viscera. Of these, the mesenteric are the vessels most frequently 
found bleeding when the abdomen is opened. 



280 GUNSHOT WOUNDS 

3. Peritonitis is the common cause of death, some time after injury. 
It may be fatal within twenty-four hours if the infection comes from 
a wound of the rectum. 

4. Infection of the retroperitoneal tissue may come from the bowel 
or the bacillus aerogenes capsulatus. In the case of the former the 
infection usually comes from wounds of the colon. 

Trench fighting has permitted the establishment of well-appointed 
operating centers close to the fighting line, so that cases of abdominal 
wounds can be collected rapidly into an operating room under the 
management of expert abdominal surgeons. This fact has materially 
changed the management of abdominal wounds in military surgery. 
The conditions on the western front so far as this class of wounds is 
concerned approximate those in civil practice in well-appointed hospi- 
tals in which the surgeons control all the environments. The rule 
of operating early has become the vogue at the casualty stations on 
the western front. The rest-treatment supplanted by morphia, which 
obtained in the Spanish-American, Anglo-Boer, Russo-Japanese, and 
other recent wars in which the mobile armies were fighting in the open, 
is no longer favored. 

•In caring for patients before operation morphine is at once em- 
ployed for the relief of pain and to allay anxiety during transport to the 
casualty station. Fluids should be administered in very moderate 
quantities. On reaching the operating hospital the patient is put to 
bed, and is given subcutaneous saline for the treatment of shock. If 
no improvement takes place hemorrhage is probably present and opera- 
tion should be undertaken. If hemorrhage is found the chances of 
saving the patient's life are good. 

At operation a paramedian incision is employed and it should be 
used in all cases unless it is contraindicated. A long incision saves 
time and shock. The first indication is to arrest hemorrhage and the 
second to systematically examine for wounds of the hollow viscera. 

In resection circular enterorrhaphy is better than lateral anasto- 
mosis. Lesions of the small bowel must be dealt with first and the 
colon next. 

The author gives no figures on the results of the cases operated 
upon but he promises to do so when a series of cases has been collected 
for six months. He states that the results secured so far indicate 
positively that the mortality at the casualty clearing stations has been 
very much reduced by early operative interference. 

We confidently believe that the experience in the world war will 
give us definite data on many mooted points in abdominal wounds by 



GUNSHOT WOUNDS OF THE ABDOMEN 281 

gunshot. We have to admit that the lesions are often different from 
those in civil life, and that in spite of the advances that have been made 
in field surgery to bring the environments under better control, safety 
in operation in war surgery will never be as promising as it is in civil 
hospitals, and that the results of operated cases can never be as 
favorable. 

Finally we may add that abdominal wounds in both Civil and 
Military practice will hereafter be inflicted by very unstable bullets, 
which travelling at great velocity, will produce ugly lesions that will 
seldom prove amenable to operative treatment. 

In the presence of a penetrating gunshot wound of the abdomen 
the military surgeon in campaign or civil surgeon in peace must decide 
at once upon the advisability of operation. 

Contraindications to Operation. — (1) A moribund condition, or 
increasing shock bordering upon profound collapse with impending 
death, contraindicates surgical aid. 

(2) If twelve hours have elapsed since the receipt of the injury the 
chances of recovery are bad. The surgeons in each case should, how- 
ever, be the judges of the advisability for operation, using the condition 
of the patient as a guide. 

(3) When symptoms of peritonitis are evident, there is but little 
hope of recovery from operation. 

(4) Unfavorable environments, inexperience on the part of the 
attending surgeon and his assistants, materially reduce the chance for 
recovery after operation. 

(5) Avoid operation on cases complicated by severe wounds of the 
chest such as would contraindicate the use of an anesthetic. 

(6) It is a question if operation is advisable in cases where the 
point of entrance is some distance from the mid line of the abdomen, 
with the course of the ball ranging antero-posteriorly. Still if opera- 
tion is done under favorable environments no harm can result. In 
these cases the large intestine has generally suffered perforation. The 
perforation lies in contact with the parietal peritoneum, the intestine 
is immobile, and in the case of perforation from small calibers, the 
intestinal contents being solid, extravasation is infrequent. 

(7) When the patient is doing well, as often happens in military 
practice after gunshot by reduced calibers eighteen to twenty-four 
hours after the receipt of the injury, operation should be withheld. 
Peritonitis more or less localized is present in all these cases, and hand- 
ling of the inflamed peritoneal surfaces in search of perforations will 



282 GUNSHOT WOUNDS 

do more harm than no operation. Indications for operation in local- 
ized peritonitis may show itself later, and when it does the danger 
from operation is trifling. Again cases that have survived eighteen 
to twenty-four hours in military practice especially belong usually 
to that class in which extravasation has failed to take place as a result 
of the small wound caused by the rifle bullet. This small opening is 
usually closed by hernia of the mucosa and exudation of plastic 
lymph, before extravasation has had time to take place; and finally, 
some of the cases in military practice which have shown negative or 
trifling symptoms after the lapse of the time above referred to, no 
doubt belong to the rare class of cases that sustain no perforation, 
although the small bullet, as already pointed out, may have crossed 
the intestinal area. 

(8) Laparotomy in military practice during active field conditions 
has proven a failure for a number of reasons. Military surgeons in 
campaign seldom get the opportunity to operate early. The cases are 
first seen at the advanced stations where the facilities for abdominal 
work seldom exist. The lack of water and sterile dressings, the diffi- 
culties which arise from want of proper shelter, and an equable tem- 
perature under canvas in all seasons of the year, as well as the difficulties 
that arise from wind, dust, flies, etc., all combine to preclude aseptic 
work, under field conditions. When the wounded finally reach the 
field hospitals where facilities for abdominal work are to be found, the 
time for safety in operation has gone by, and if it has not, the surgeons 
are so occupied in doing necessary work on a great number of other 
wounded that common justice to the greater number does not permit 
the employment of a large operating staff, with the necessary time and 
personnel, to be detached to do abdominal work on comparatively 
few wounded. 

Indications for Operation. — (1) Protrusion of the intestine from the 
wound soiled by dirt and feces, when the patient's condition permits, 
demands immediate operation, even though the surroundings are not 
entirely satisfactory. 

(2) When the symptoms indicate that internal hemorrhage is 
going on, with chance of saving life, laparotomy and the ligation of 
bleeding vessels should be undertaken though the environments are 
precarious. 

(3) When a bullet has crossed the intestinal area, if the time after 
the injury and the environments permit, laparotomy should be done 
promptly. 



GUNSHOT WOUNDS OF THE ABDOMEN 283 

Operation: Having determined by the condition of the patient 
and the nature of the injury that abdominal section is necessary the 
patient should be anesthetized preferably with ether. A median 
incision giving ample room should be made in all cases in which 
the ball has entered near the mid line and in which the track of the 
bullet has crossed a median plane. When the course of the ball is 
well established and located laterally the incision may be made over 
the corresponding side. Upon reaching the abdominal cavity bleed- 
ing should be promptly arrested by ligation, or pressure with a gauze 
pad. The extravasated blood should next be removed from the 
peritoneal cavity by sponging. 

Intestinal perforation should be closed by suture at once if small, 
and when large the lumen above and below the perforation should 
be clamped with rubber-covered forceps for the time being. The 
method of repair of the latter and all visceral injuries will be dealt 
with under appropriate headings later. 

Drainage should be employed wherever the lacerated condition 
of the tissues tends to cause necrosis, and whenever bleeding surfaces 
require the application of pressure by tamponade. The latter is 
preferable to the actual cautery, which should be avoided. 

Stimulation by strychnia sulphate hypodermically, and the use of 
salt solution with adrenalin, should be employed whenever the patient's 
condition demands it. 

Wounds of the Small Intestine. — In point of frequency wounds of 
the small intestines take precedence over the rest of the abdominal 
viscera. As we have already intimated the small intestines make a 
marvelous escape in a certain percentage of antero-posterior shots, 
but it may be laid down as a rule that transverse and oblique shots 
through the abdomen, in the vast majority of cases cause multiple 
perforations of the intestinal tube. As many as twenty-eight perfora- 
tions have been thus encountered. Free extravasation of fluid fecal 
matter is favored by the number of perforations. Some of the latter 
are slit-like tears, which occur in the long axis of the gut. The ten- 
dency to the early development of septic peritonitis is almost invaria- 
ble. In penetrating wounds of the abdominal cavity the small intes- 
tines are said to be perforated in 65 per cent, of the cases and death 
will take place in percentages which will vary with the character of 
the lesion, and the latter, as we have already stated, depends largely 
upon the sectional area and velocity of the projectile. Peritonitis 
and internal hemorrhage are the common causes of death. Perfora- 



284 GUNSHOT WOUNDS 

tions from small calibers are usually closed by hernia of the mucosa. 
The escape of the contents is further aided in some cases by arrest 
of peristalsis and the presence of plastic lymph, which is thrown out 
in a short space of time. The hernia caused by the everted mucosa 
may occlude the perforation so perfectly that hemorrhage will find 
no access to the lumen of the gut, so that in cases of multiple perfora- 
tion there may be little or no blood in the stools. Wounds of the 
mesenteric border favor the presence of hemorrhage. Injury to the 
blood supply of certain areas of gut, as occurs, for instance, in shots 
through the mesenteric border without perforation of the gut, is apt 
to end in gangrene. Perforative septic peritonitis usually develops, 
in the first few hours. Depending upon the virulency of the infection, 
death will occur in thirty-six to forty-eight hours in the large majority 
of cases. 

The tendency to hemorrhage, or the development of peritonitis, 
depends largely upon the character of the wound. Wounds by small 
calibers, animated by low velocity, are prone to local peritonitis or 
recovery. No doubt many of the soldiers who recover so unexpectedly 
in military practice owe their lives to the small perforations that 
result from projectiles of reduced-caliber rifles with low remaining 
velocities. Surgeons in civil life get their best results in operated and 
non-operated cases from wounds inflicted by the smaller calibers. 

Symptoms. — While dealing with general symptoms of gunshot 
wounds of the abdomen, to which the reader is referred, we mentioned 
all the symptoms likely to arise from injury to the small intestine. 
The surgeon should be on the alert for the presence of hemorrhage, 
as this is the condition next to shock that will require his immediate 
attention. Unlike shock, it does not yield to remedial measures, and 
it is not so readily diagnosed. Hemorrhage will not appear externally 
unless it be in the case of large external wounds. We must look for 
the presence of fluid in the abdominal cavity as this is revealed to us 
by physical signs. Areas of dullness which progressively increase 
about the flanks, associated with persistent shock, indicate that hemor- 
rhage is going on. 

Treatment. — The treatment of gunshot wounds of the small intes- 
tines requires that all perforations be located by searching the entire 
length of the gut. To do this properly without overlooking some of 
the perforations, it is better to commence the search at the ileocecal 
junction, tracing the small intestine rapidly upward, each loop being 
carefully returned as soon as examined. Perforations should be closed 



GUNSHOT WOUNDS OF THE ABDOMEN 285 

as found. Large perforations and injuries on the mesenteric border 
that call for resection should be controlled by clamps and passed over 
to be attended to later. Small perforations on the convex border of 
the small intestine may be closed by continued or purse-string suture. 
Larger perforations are closed by a line of seromuscular sutures running 
with the short axis of the gut, and when necessary two lines of sutures, 
one to include all the coats, and a superficial line to include the sero- 
muscular layer. In much larger perforations the line of sutures should 
run in a direction coincident with the lumen of the gut provided not 
more than one-half the lumen is taken up by the suturing, otherwise 
resection is called for. 

Special care is required in dealing with injuries at the mesenteric 
border lest gangrene of the gut take place from interference with the 
blood supply. Injuries involving 1/2 inch or more of the tissue in 
this location demand resection; any injury less than 1/2 inch may 
be closed by suture depending upon the judgment of the operator. 

Wounds between the mesenteric and convex borders when located 
nearer the former may at times threaten the blood supply of the con- 
vex border. In such cases resection is called for. All suturing should 
be done with a straight needle threaded with fine silk, six interrupted 
sutures to the inch will suffice. When resection is done the end-to-end 
approximation should be accomplished with the Czerny-Lembert 
suture and in cases where the operator is not experienced or where it 
is necessary to save time a Murphy button should be used. When 
two or more resections are to be performed in the course of 2 or 3 feet 
of gut, it is better to sacrifice all of the intervening gut and bring the 
ends together by one circular enterorrhaphy, rather than prolong the 
operation and add to the shock by doing two resections. 

Search for perforations in the large intestine is made by using the 
ileo-cecal valve as a starting point and tracing the gut upward. Closure 
of perforations in large intestines covered by peritoneum is similar to 
those in the small intestine, the line of suture with reference to the axis 
of the gut is not so important, and resections are seldom called for. 

After all perforations have been repaired cleansing the peritoneal 
cavity is next in order. Irrigation is not advisable unless deemed 
necessary from extensive fouling by the contents of the alimentary 
canal. Localized extravasations are best removed with moist sponges. 
If irrigation is necessary, it should be done by flushing the peritoneal 
cavity with hot normal salt solution. 

In all cases it is safer to drain than not to drain. Drainage at the 



286 GUNSHOT WOUNDS 

most dependent point is specially indicated in cases likely to be followed 
by coagulation necrosis and those where extravasation has been marked. 

Gunshot Wounds of the Stomach. — Wounds of the stomach were 
very fatal in the days of the old armament. Aside from the dangers of 
sepsis, the wounds of that day were large and there was always danger 
of free extravasation of the irritating stomach contents with resulting 
peritonitis, and, as the records show, great tendency to subphrenic 
abscess. 

In the distended state, the relation of the stomach wall to the par- 
ietes makes it an easy target for perforation. In point of frequency 
wounds of the stomach come after those of the intestine and liver. 
There were sixty-four cases treated in our hospitals during the Civil 
War, but on account of the fatal character of complicating wounds to 
adjacent organs, this number only represented a fraction of the wounds 
of the stomach received in action. 

In recent wars uncomplicated wounds of the stomach have frequently 
ended in recovery. This has been attributed to the empty condition 
of the organ which so often obtains among soldiers in active campaign, 
the thickness of the stomach wall, and the narrow channel made by 
the bullet. Stevenson mentions twelve cases in the Anglo-Boer War 
with two deaths, one as a result of peritonitis and the other from 
hemorrhage. Follenfant states that the statistics at Kharbine in 1904 
gave forty-two deaths out of 252 penetrating wounds of the abdomen, 
with lesion of the stomach and intestine. 

Wounds of the stomach are apt to be complicated by the presence 
of other wounds such as those of the left kidney, spleen, liver, pancreas, 
transverse colon, diaphragm and thoracic viscera. 

The prognosis as reported by different authors is variable. 
Laplace 1 has found gunshot wounds from small calibers to end in 
recovery in the majority of his cases, while MacCormac 2 states that 
99 per cent, of gastric perforations end in death. 

The prognosis of uncomplicated stomach wounds will largely depend 
upon the character of the wound as influenced by sectional area, veloc- 
ity, and resistance on impact. Wounds inflicted by the high-power rifle 
at proximal ranges will show explosive effects in accordance with the 
amount of fluid in the viscus. All wounds showing explosive effects are 
rapidly fatal. 

Repair of Injury to the Stomach. — Wound of the stomach should be 

1 Sajous' Annual and Analytical Cyclopedia of Prac. of Medicine, Vol. I, 1899. 
2 Tillmann's Text-book of Surgery (Tilton), Vol. Ill, 1898. 



GUNSHOT WOUNDS OF THE ABDOMEN 287 

closed by Lembert suture in the direction of blood vessels. If the 
wound is large the Czerny-Lembert suture is preferable. Wounds of the 
posterior wall are more satisfactorily reached by breaking through the 
transverse meso-colon. When the wound of the stomach is compli- 
cated by injury to the pancreas posterior drainage through the skin 
of the lumbar region should be made. 

Wounds of the Large Intestine. — Gunshot wounds of the large 
bowel covered by peritoneum, except those of the transverse colon, are 
never so fatal as those of the small intestine. This was true of gun- 
shot injuries by the old armament when the lesion was generally more 
severe than that inflicted by the projectiles of the present day. Otis 
records fifty-nine cases of spontaneous recovery from gunshot of the 
cecum and ascending colon, the descending colon and sigmoid flexure, 
and a few instances of the transverse colon. Nearly all the cases 
were complicated by fecal fistula which closed spontaneously in the 
large majority of the cases. Forty-one of the fifty-nine cases were still 
living after the lapse of twelve years or more. 

The more hopeful outcome of injury to this part of the intestine is 
ascribed to the fact that the walls of the gut are thicker than those of 
the small intestine, and the aperture in them is partially closed by the 
greater amount of tissue involved in the perforation. In addition the 
gut is fixed to the wall of the abdomen by the overlying peritoneum, it 
is therefore immobile, extravasation is not so likely to occur; and again, 
the contents are usually more solid. It may be stated also that other 
organs are not so apt to be implicated in antero-posterior shots which 
penetrate in the line of the ascending and descending colons. In forty 
cases in the Anglo-Boer War Stevenson fixes the mortality at 32.5 per 
cent., although some of them had sustained injury to the liver, bladder, 
and kidney. 

Wounds of the Sigmoid Flexure and Rectum. — Wounds of the 
former are less fatal by far than those of any portion of the intestinal 
tract. Those of the rectum belong to the hopeful class, when uncom- 
plicated. They are often complicated, however, by shots through the 
bladder, the adjoining pelvic bones, or femur. Such shots are prone 
to the development of fecal fistula, cellulitis, and septicemia, the latter 
being a frequent cause of death. Stevenson records thirteen cases of 
gunshot wound of the sigmoid flexure and rectum in the Anglo-Boer 
War with a mortality of 30.7 per cent. 

Treatment of Gunshot Wounds of the Rectum, and Colon not 
Covered by Peritoneum. — Until the Anglo-Boer War gunshot of those 



288 GUNSHOT WOUNDS 

parts of the colon extraperitoneal^ located were supposed to be at- 
tended with less danger to life than the lesions connected with the peri- 
toneal cavity. Mr. Makins, experience is decidedly opposed to this 
idea. He saw several such lesions, every one of which ended fatally, 
and likewise he found that extra- as compared to intraperitoneal 
wounds of the bladder were also more fatal, to which we will refer 
later. Like gunshot of the rectum the indications for treatment in 
colon wounds uncovered by peritoneum are the relief of fistula, cellu- 
litis, and septicemia which result from extravasation of intestinal 
contents into the tissues outside the gut. Whenever practicable 
Mr. Makins enlarged the wounds leading to the colon and brought 
the gut to the surface. The artificial opening in the latter was at- 
tended to later. In like cases Colonel Stevenson advises the introduc- 
tion of 1/2-inch tube as far as the opening in the bowel. Gauze is 
packed around the tube to prevent the intestinal contents from con- 
taminating the sides of the wound. In such cases the prime indi- 
cation is the establishment of drainage, and either method when 
properly carried out should accomplish this end. 

In wounds of the rectum colotomy has been advised and prac- 
tised to prevent the passage of feces into the rectum. Otis calls 
attention to the fact that the older surgeons recommended and prac- 
tised division of the anal sphincters to prevent extravasation leading 
to cellulitis and septicemia, and for the cure of fistulae that often per- 
sist through wounds of the skin in adjoining parts. 

Gunshot Wounds of the Liver and Gall Bladder. — Uncompli- 
cated wounds of the liver from small-caliber bullets recover in the vast 
majority of cases. When complicated by hemorrhage or injury to 
other viscera the prognosis is not so good. Hemorrhage is probably 
the most fatal of the complications, and this is proportional to the size 
of the wound and the liability to injury to the larger vessels in the 
liver substance. Reporters in recent wars have frequently remarked 
upon the absence of wounds showing explosive effects in the liver and 
other viscera in hospital cases. Field hospitals are not the place to 
look for such cases. They die on the field in a few moments, and 
never live long enough to receive hospital care. 

Wounds of the liver are often complicated with wounds of the 
thoracic viscera, stomach, intestine or kidney. The more serious 
complications are those involving the thoracic viscera and diaphragm. 
Such cases are very apt to die from pleural septicemia. Wounds com- 
plicated by injury to the portal vein are usually rapidly fatal. Those 



GUNSHOT WOUNDS OF THE ABDOMEN 289 

complicating the gall bladder are apt to cause biliary fistula, and the 
latter is most frequently seen when the bullet scores the surface of the 
organ (Makins). 

The symptoms, aside from hemorrhage in a certain class of cases, 
are not typical. One has to be guided largely by the location of the 
apertures made by the bullet. Icterus occurs in one-fifth of the 
cases according to Edler. 1 In cases with extravasation of bile in the 
peritoneum, there is icterus, also cholemia, as evidenced by pruritus, 
nausea and mental hebetude. Such cases are rapidly fatal unless 
biliary fistula is established with free drainage. 

In the Civil War Otis records fifty-nine uncomplicated gunshot 
wounds of the liver with twenty-five recoveries. Stevenson reports 
twenty-eight cases in South Africa with a mortality of 28.5 per cent, 
and Follenfant gives a mortality of 19.3 per cent, in thirty-one cases 
in the statistics at Kharbine in 1904. 

Gunshot wound of the gall bladder is rarely referred to in the 
literature, a fact which no doubt testifies to the fatality which attends 
such cases. The diagnosis has to be made by the location of the ex- 
ternal wounds, the occasional flow of bile externally, and active re- 
action on the part of the peritoneum. The diagnosis is no more than 
a conjecture until the peritoneum has been opened. 

Otis mentions a case which occurred in the Civil War and which 
ended in recovery. The ball entered on the right side near the carti- 
lage of the tenth rib 3 or 4 inches from the umbilicus, and escaped 
on a level with the twelfth dorsal vertebra. Seventeen days after 
the injury, in an effort to sit on the edge of his bed, there was a sudden 
escape of about 1 pint of bile from the wound of entrance. For 
seventeen days thereafter about a pint of bile continued to escape 
daily from the wound. The flow was greatest between the hours of 
3 and 6 p.m. The stools were clayey, there was distaste for food. 

Treatment. — Gunshot of the liver uncomplicated by hemorrhage 
requires no surgical interference. This fact is prominently empha- 
sized by the large number of recoveries of gunshot of the liver in 
recent campaigns. Fischer states that they were regarded among the 
slight or humane wounds by some of the surgeons in the Manchurian 
campaign. The impossibility of excluding complications often ren- 
ders exploratory laparotomy essential. Hemorrhage is preferably 
controlled by a narrow gauze packing, the end of which should be left 
protruding through the abdominal wall. In larger wounds when 

1 Archiv f. klin. Chirurg., Bd. XXXIV, Ch. IV, 1887. 
19 



290 GUNSHOT WOUNDS 

bleeding still continues, the best way to control the hemorrhage is by 
packing the cavity with gauze, or when practicable the sides of the 
wound should be brought together by suture. A straight blunt 
needle armed with number 3 or 4 catgut is preferable for the purpose. 

When the gall bladder is wounded and the loss of substance is 
extensive cholecystectomy should be practised. In small perforations 
the wound may be closed by silk sutures or the edges of the perforation 
may be sewed to the abdominal wall as in cholecystectomy. 

The following case bears upon the wisdom of early operation and 
it marks one of the triumphs of the modern method of treatment 
of abdominal wounds when the surgeon can control the environments. 

First Lieutenant Clarence E. Fronk, 1 Medical Corps, U. S. Army, 
reports the case as follows: " A Philippino woman, fifty years old, was 
accidentally shot at camp McGrath, P. I., at 5.30 p. m., Oct. 2, 1911, 
while she was in a stooping posture, facing the gun when it was dis- 
charged. The missile was a 32-caliber slug fired from a No. 12 auto- 
matic shotgun. She was examined in the post hospital at 11 p. m. 
when the following condition was noted : 

"A wound about 1/8 inch in diameter, 1 1/2 inches below and 1 
inch to right of ensiform cartilage. No wound of exit, but the eleventh 
rib, left side, was fractured at its center and the missile could be pal- 
pated just under the skin at this place. The wound of entrance was 
enlarged, and by exploring with the finger, its entrance into the peri- 
toneal cavity was confirmed. The woman was in a state of collapse, 
with weak, frequent and thready pulse, and shallow, rapid respiration. 
Immediately before and during the examination she vomited a large 
quantity of clotted blood mixed with stomach contents. 

"The case clearly demanded surgical intervention and, consent 
being given by the patient and relatives, she was prepared for imme- 
diate laparotomy. 

" Sterilization of the operative area was accomplished with 7 per 
cent, tincture of iodine. The operation was begun at 12.30 a. m., 
Oct. 3, 1911, under chloroform anesthesia, it not being thought safe 
to use ether, working as we were with open oil lights. 

" An incision 3 inches long was made through the left rectus muscle. 
Upon incising the peritoneum, the abdominal cavity was found full 
of fluid blood which welled up from the region of the gall bladder. The 
latter was located abnormally far to the left; it being directly in the 
line of incision. The transverse colon was delivered and examined 

1 Military Surgeon, Vol. XXX, No. 6, June, 1912. 



GUNSHOT WOUNDS OF THE ABDOMEN 291 

and then the stomach. No wound being discovered in either and feel- 
ing certain that the latter had been perforated, owing to the patient 
having vomited a large amount of blood, an opening was made in the 
transverse mesocolon and the stomach examined posteriorly; but care- 
ful search revealed no injury. The liver and gall bladder were then 
examined and a perforation found in the fundus of the latter from 
which the blood was flowing freely. This wound was closed with a 
continuous silk suture, reinforced by a Lembert suture, which effect- 
ively controlled the hemorrhage. The patient's condition being 
extremely poor, a hasty search was made for further injury to the 
liver, pancreas, duodenum, etc., but none was found. The anesthetic 
was stopped, the blood mopped out with dry gauze, a quart of hot 
normal saline solution poured into the abdomen and the wound closed 
in layers without drainage. 

"The entire operation consumed about thirty minutes. Upon 
removal from the table, the patient's pulse was 140 to the minute 
and imperceptible at the wrist. She was placed in bed, surrounded by 
hot water bottles and given 1000 c.c. of normal saline solution into the 
median basilic vein, to which she responded promptly. Salt solution 
per rectum by Murphy's method was begun and continued during the 
following twenty-four hours, taking in all about 3000 c.c. Con- 
valescence was rapid and uneventful, the wound healing by primary 
union. 

"The missile was removed at the end of two weeks and proved 
to be an irregular shaped 'slug' about .32 inch in caliber. 

"The peculiar features of this case are: 

"(A) The large amount of blood vomited with no injury to the 
stomach, the bleeding being from the cystic artery into the gall bladder 
and then into the stomach by way of the cystic and common ducts 
and duodenum. 

" (B) The possibility of a missile of such a size passing through 
this region with no injuries discoverable in the other organs and the 
excessive hemorrhage from the gall bladder wound." The patient's 
recovery was uninterrupted. 

Gunshot Wounds of the Pancreas. — Wounds of this organ have 
not been frequently noted in the literature. They are usually attended 
with primary hemorrhage and death occurs early. Its intimate rela- 
tion with other viscera like the spleen, liver, stomach, duodenum, the 
large vessels and the spinal column, makes wounds of the pancreas very 
fatal on the field or soon after receipt of the injury. Otis refers to 



292 GUNSHOT WOUNDS 

five cases occurring in the Civil War. "In one of the cases the ball 
entered the right side below the ribs and emerged on the left side." 
Two days later part of the pancreas the size of an egg protruded from 
one of the wounds. The pedicle of the tumor was strangulated by 
means of a silver wire and subsequently cut through with scissors. 
No dangerous symptoms transpired and the patient was up and moving 
about the hospital at the end of five weeks. Three of the five cases 
reported by Otis lived from twelve to fifteen days. The causes of 
death in four of the fatal cases were shock and peritonitis in one, and 
secondary hemorrhage in the other three. In four of the cases the 
bullet entered behind and coursed transversely through the body. 
In one case the ball entered anteriorly near the end of the ensiform 
cartilage with probable involvement of the stomach. In three of the 
cases the diagnosis was not made until post-mortem. The autopsies 
gave but little to note on the morbid anatomy and the clinical his- 
tories pointed to no special symptoms referable to traumatism of the 
pancreas. 

Treatment of Gunshot of the Pancreas. — The surgical indications 
in all wounds of the pancreas are : arrest of hemorrhage and establish- 
ment of drainage. The former is to be controlled by suture when 
possible, otherwise by tampon. Lumbar drainage is always preferable. 
In twelve cases 1 of gunshot of the pancreas reported by Von Mikulicz- 
Radecki laparotomy was done in five cases with three recoveries. The 
seven cases not operated upon died. 

Gunshot Wounds of the Spleen. — Wounds of this organ are prone 
to hemorrhage from the extreme vascularity and friable nature of the 
tissues. The prognosis is further hampered by accompanying wounds of 
other organs like the left kidney, the stomach, diaphragm, pleura, lungs 
and other viscera. The diagnosis usually rests upon a study of the 
bullet's track. Four cases were diagnosed in the Anglo-Boer War with 
one recovery (Stevenson) . The fact that wounds of the spleen are rare 
in the literature suggests their extreme fatality. Makins points to a 
case in South Africa complicated by renal injury. At time of death 
three weeks later, the wound in the spleen had cicatrized. The same 
author is of the opinion that wounds of the spleen from reduced-caliber 
bullets are seldom accompanied by hemorrhage since he never saw a 
case with dullness in the flanks to indicate the presence of internal 
hemorrhage. In the cases he saw the diagnosis was made by the loca- 
tion of the external wounds and the bullet-track so that the element 

1 Annals of Surgery, July, 1903. 



GUNSHOT WOUNDS OF THE ABDOMEN 293 

of mistaken diagnosis has to be considered. Follenf ant gives one death 
in seven cases out of the Kharbine statistics for 1904. 

Treatment. — The surgical indications are control of hemorrhage 
and when this is copious the abdomen needs to be opened promptly. 
When the bleeding cannot be controlled by suture, splenectomy is to 
be resorted to. 

Gunshot Wounds of the Kidney. — Uncomplicated kidney wounds 
by gunshot rarely occur. The spleen, intestine, stomach, or colon is 
usually involved. The lesion may or may not involve the peritoneum. 
Wounds of the peripheral part of the organ, near the extremities or 
convex border, offer a better prognosis than those near the central part. 
If the pelvis of the kidney is implicated, the prognosis is bad, because 
escape of blood and urine in the peritoneal cavity are prone to set up 
infection. Extraperitoneal tracks implicating the pelvis or hilum of 
the kidney are apt to end in perinephritic abscess from extravasation 
of urine in the surrounding tissues. Urinary fistula is one of the 
sequelae of such cases. Fistula persists a long time, but eventually 
closes spontaneously. 

With the use of the old armament the amount of tissue laceration 
was great and the fatality was in keeping with the amount of lesion. 
Otis reports seventy-eight cases in the Civil War with a mortality of 
66.2 per cent. Wounds of the kidney by the reduced-caliber bullet 
in recent wars have not been so fatal, especially when the bullet has 
traversed the extremities or convex border of the organ, away from 
the pelvis and hilum. At the mid ranges the bullet makes a clean per- 
foration which shows a tendency to heal in a few days, without serious 
symptoms. 1 Stevenson reports thirteen cases of wound of the kidney 
out of 207 gunshot wounds of the abdomen, with two deaths. Only 
two of the cases were uncomplicated. The other organs involved were 
the spleen 1, stomach 2, large intestine 1, lung 2, liver 1. Such a small 
mortality, 15.3 per cent., speaks well for the prognosis after wounds of 
the kidney and other organs as well. 

The mortality of the uncomplicated cases is still lower, but we must 
remember that the greater penetration of the new projectile has a 
tendency to increase the percentage of complicated wounds and that 
associated injuries of the lungs, spine, liver, etc., are far more common 
than formerly. 

Injury by shrapnel balls and pieces of shell are prone to hemorrhage 
and also sepsis, in spite of the improvement in wound treatment, and 

1 Makins, op. cit. 



294 GUNSHOT WOUNDS 

the mortality is but a trifle less than formerly 1 for wounds from this 
source. 

Symptoms. — Pain and hematuria are the two symptoms which 
specially indicate renal perforation. The pain usually radiates down- 
ward extending to the genitals and thighs, and a desire to urinate and 
retraction of the testicle are present. Hematuria is present in per- 
forating wound of any part of the kidney. It is only absent in cases 
which have suffered division of the ureter or those cases where blood 
accumulates in the pelvis of the kidney from which the ureter is 
occluded. Only clear urine from the other kidney will then reach 
the bladder. In certain cases with extensive lesion there may be 
suspended excretion of the kidney with absence of hematuria. 

Treatment. — Wound of the kidney generally calls for abdomnial 
section because the lesion is so often complicated by injury to other 
organs. When the bullet has severed the renal vessels or committed 
great destruction of kidney tissue nephrectomy is demanded. As un- 
complicated injuries by the modern rifle bullet, wounds of the kidney 
heal rapidly without serious symptoms beyond transient hematuria 
(Makins). The treatment in such cases is rest and the administration 
of opium when hematuria is pronounced. Wound of the pelvis or 
ureter demands nephrotomy in order to establish temporary drainage 
for the urine. If the wound is in the loin, free drainage by enlarging 
the wound should be practised to prevent cellulitis and septicemia from 
extravasated urine. If hydronephrosis develops it should be relieved 
by incision and drainage. 

The following case of complicated gunshot wound of the kidney 
treated expectantly on account of the unfavorable conditions in active 
campaign shows the chance of recovery from gunshot by the new mili- 
tary rifle bullet. Major T. T. Knox, 1st U. S. Cavalry, was shot on 
June 25, during the advance on Santiago de Cuba. A Mauser bullet 
entered the back on the right side and ranging forward emerged through 
the skin opposite the ninth and tenth ribs. He was seen five hours 
later by Doctor W. E. Parker, who expressed the opinion that the ball 
had penetrated the kidney and liver. His pulse was 130, "he was in 
a cold clammy sweat and his urine was full of blood .... His con- 
dition was such that he would have died on the table had he been sub- 
jected to laparotomy. He was given strychnia and atropin under 
the skin every three hours. At the end of twenty-four hours tympa- 
nites developed which disappeared after a full dose of magnesium sul- 

1 Graf and Hildebrandt, op. cit. 



GUNSHOT WOUNDS OF THE ABDOMEN 295 

phate. The blood in the urine gradually disappeared and the officer 
was eventually restored to full duty." 

Gunshot Wound of the Adrenal Gland. — Injury to this organ by 
gunshot is necessarily rare on account of its diminutive size as compared 
to other organs in the body. Otis makes reference to but one case dur- 
ing the Civil War. The ball, after fracturing the ninth rib, penetrating 
the left lung and diaphragm, lodged in the left suprarenal gland. The 
man died four weeks later of pyemia. There was a marked icteroid 
discoloration which it was considered might have been the result of 
pigment deposit after the bronzing described by Addison. The sug- 
gestion is of value in the study of future cases. 

Treatment. — No treatment of a surgical nature is indicated for in- 
jury to the gland itself. 

Wounds of the Urinary Bladder. — Gunshot wounds of this viscus 
were classed among dangerous wounds in the days of the old armament. 
The mortality was 63 per cent, in the Franco-German War, 1870-71. 
Otis refers to 183 recorded cases in the Civil War with a mortality of 
47.5 per cent. The majority of those who recovered from the immedi- 
ate effects of the battle injury "suffered from grave disabilities, and many 
from distressing infirmities." Much of the protracted suffering was 
the result of fistula? from necrosis of the pelvic bones; rectovesical fistula? 
and stone in the bladder as a result of lodgment of foreign bodies in the 
cavity of the organ, such as the projectile itself or fragments thereof, 
fragments of bone, bits of clothing, hair, particles of integument, and 
splinters of wood. Our present methods of wound treatment can now 
forestall the majority of the complications and disabilities mentioned. 
This, with the beneficence which comes from the use of the reduced- 
caliber projectiles, has demonstrated that we may expect a favorable 
prognosis in the large majority of bladder wounds in the wars of the 
future. Mr. Makins has called our attention to the outcome of extra- 
peritoneal as compared to intra-peritoneal wounds. In the former 
there is greater tendency to complications as a result of suppurative 
cellulitis and septicemia, complications that require active surgical 
interference. Intraperitoneal perforations exhibit less danger pro- 
vided the urine is of normal character. 

The character of the wound and the prognosis are very much 
influenced if the bladder is full or empty at the moment of impact. In 
the latter condition the small jacketed bullet makes a channel which is 
soon closed by the contractile tissue of the viscus. If, however, the 
bladder is full the contents escape through the perforations and the 



296 GUNSHOT WOUNDS 

accumulating urine continues to escape. Makins noticed that un- 
complicated peritoneal wounds of the bladder recovered spontaneously 
in a considerable proportion of the cases, but extra-peritoneal perfora- 
tions were more apt to end in troublesome complications, while all 
wounds at the base of the bladder were fatal, in his experience 

The superior penetration of the new armament has added to the 
number of associated wounds that attend injury to the urinary bladder. 
The bones of the pelvis, the hip-joint, adjoining vessels and nerves, the 
peritoneal cavity and its different viscera, the ureters, kidneys, genitals, 
and rectum are often implicated. The order of frequency of wounds of 
adjoining parts is as follows: bones of the pelvis, intestines, rectum, 
large blood-vessels, genitals, large nerves, kidneys, ureters. 

Stevenson notes seventeen cases in the Anglo-Boer War with three 
deaths. Two of the cases passed the bullet per urethram. Follenfant 
gives a mortality of 29.2 per cent, out of fourteen cases in the Kharbine 
statistics for 1904. 

Symptoms. — Hemorrhage and an empty bladder are the two prin- 
cipal symptoms. The latter is generally associated with intra-perito- 
neal wounds, the urine escaping into the peritoneal cavity, while hemor- 
rhage in the organ is most generally associated with extra-peritoneal 
injury. The latter are apt to show signs of inflammation from extra- 
vasation of urine and later fistula from which urine dribbles. Wounds 
implicating the bladder and rectum are apt to end in vesicorectal fistula 
with escape of urine per rectum, or feces and gas may escape per ure- 
thram. The appearance of blood in the urine is one of the early symp- 
toms of gunshot wound of the bladder. The bladder is sometimes filled 
with blood clots which cause retention and infection unless promptly 
relieved. Abnormal urine escaping in the peritoneal cavity will set 
up peritonitis very promptly. The course of the ball will often indi- 
cate injury to the viscus. The bullet's track is generally disposed 
antero-posteriorly through or just above the pelvis, but more often it 
enters one groin and ranging downward and backward it makes its 
exit through the opposite buttock. Shots implicating the bladder are 
also disposed transversely just behind the symphysis pubis. 

Treatment. — The surgical indications differ in accordance with 
the character of the wound. Intraperitoneal wounds of the bladder 
demand laparotomy in all cases in which the environments are favor- 
able for operation. Early laparotomy favors recovery in nearly all 
uncomplicated bladder wounds. As a matter of precaution the 
urethra should be cleansed by irrigation with a mild antiseptic solu- 



GUNSHOT WOUNDS OF THE ABDOMEN 297 

tion after which a sterile catheter is introduced as far as the bladder 
and secured in place. This is done to distend the bladder in order 
to bring the perforation into view if necessary, and to drain the viscus 
in the after treatment. 

The perforation in the bladder is brought together by a deep and 
superficial line of sutures. Urethral siphonage is maintained for 
forty-eight to seventy-two hours subsequently. We should much 
prefer to maintain drainage through a perineal section in the regular 
way as practised after urethral and bladder operations for other causes. 
The difficulty of keeping a catheter in place in field conditions espe- 
cially is very great. When the environments are such in field practice 
that laparotomy is contraindicated, we should recommend perineal 
drainage, an operation which is easily and quickly done, as the best 
means of keeping the bladder free of urine. In gunshot from reduced- 
caliber bullets where the tendency to leakage of urine into the peri- 
toneal cavity is not marked external perineal urethrotomy would 
establish an additional precaution against extravasation. 

Extraperitoneal wounds of the urinary bladder are best treated 
by keeping the bladder empty. If the external wound cannot be 
readily drained, the latter should be accomplished by a suprapubic 
cystotomy or a perineal section and for field conditions, preferably 
the latter. 

GUNSHOT WOUNDS OF THE EXTERNAL GENITAL ORGANS 

Wounds of the genitals by gunshot form a comparatively small 
group of the wounds in war. They were never considered dangerous 
in themselves when inflicted by the old armament, and they are very 
much less so now. 

The wounds of this class include the anatomical parts concerned, 
viz., the penis, urethra, testicles and vas deferens. 

Wounds of the Penis. — Otis reported 309 cases from the Civil 
War with a mortality of 13.2 per cent., principally due to grave 
complications and injuries received elsewhere, as gunshot fracture 
of the pelvis and femur. Some of the less complicated cases succumbed 
to diseases like small-pox, tetanus, pneumonia, etc. 

Notwithstanding the large-caliber bullets of that day, Otis mentions 
five cases of lodged balls in the penis, one of the missiles was conoidal 
in shape and weighed 838 grains when it was removed from the root 
of the organ, Fig. 123. 



298 



GUNSHOT WOUNDS 



The severity of these wounds is necessarily less with the smaller 
calibers. The wounds of the skin and erectile tissue are of smaller 
diameter than the projectile. Contrary to what might be expected 
hemorrhage is not frequent in cases of injury to the large vessels 
supplying the penis. Hematomata of varying sizes and extent are 
frequent. Schaeffer mentions a case in which the bullet penetrated 
the glans and enfiladed the penis posteriorly to the bladder when the 

former was apparently in a state of 
erection. The more frequent wounds, 
however, are directed antero-posteriorly 
or vice versa. In some cases the ball 
enters the neighborhood of the pubis 
and emerges behind the scrotum while 
other shots are disposed transversely. 
The lesion may consist of a furrow, or 
complete perforation, while wounds 
from shell fragments have been known 
to produce entire ablation of the penis. 
Wounds of the Urethra. — The more 
important wounds of the penis are those 
which include lesion of the urethra. 
Otis reported 105 cases in the Civil War 
fig. 123.— Bali excised from the with twenty-two deaths. The fatali- 

penis. Spec. 3146 1. Army Medical ,• vi ,-, £ ,1 

Museum collection. ties llke those of the P ems P™per were 

often due to severe complications in 
adjoining anatomical structures. The uncomplicated cases were 
fatal from " exhaustion," " urinary infiltration/' " phlebitis," "dry 
gangrene," etc., causes that are more often preventable under present 
modes of treatment. 

The amount of lesion to the urethra from the military rifle bullet 
is not so extensive. The canal may be only partially, or it may be 
entirely cut across. 

The indications are to prevent extravasation of urine in the sur- 
rounding tissues which is apt to result from mechanical impediment 
to the free flow of urine. When practicable the opening in the ure- 
thra should be located and a soft catheter should be passed through 
the opening into the urethra as far as the bladder. If the flow is 
impeded and retention takes place, suprapubic aspiration or incision 
should be practised after which the patency of the urethral outlet 
should be established. Drainage is the prime indication and when- 




GUNSHOT WOUNDS OF THE ABDOMEN 299 

ever necessary perineal section should be done. Wounds of the 
urethra from the reduced-caliber bullets in recent wars are said to 
heal readily with few complications. The occurrence of urethral 
fistula is treated in the usual way. 

Wounds of the Testicles. — Otis records 586 gunshot wounds of the 
testicle with a mortality of 11.2 per cent. The majority consisted of 
lacerated wounds of one or both testes with accompanying wounds of 
neighboring parts like the penis, thighs, perineum, pelvis. The 
deaths were mostly due to the complicating wounds. 

Wounds of the testes are naturally influenced by the size of the 
projectile and consequently wounds of the testicle and scrotum by the 
reduced caliber jacketed bullet exhibit small perforations, which heal 
readily. 

Injury to the testicle is attended with more or less shock, vomiting 
and pain radiating into the abdomen. Hematoma in the scrotum is 
not uncommon. Should infection result it may extend to the tunica 
vaginalis and testicle with resulting suppuration. 

Treatment of wounds of the testicle consists in a clean dressing and 
conservative management unless suppuration supervenes when free 
drainage should be established, but removal of the organ in the major- 
ity of the cases with suppuration becomes necessary. In cases exhib- 
iting considerable laceration of the testicle castration should be 
practised. 

Wounds of the Spermatic Cord. — This class of wounds is very 
rare. They usually consist of contusions, transverse or oblique 
wounds. Otis records thirty-two cases with two deaths. The pub- 
lished reports from recent wars make but few references to gunshot of 
the cord. 

Hematocele and sanguinous infiltration are usually present with 
the immediate symptoms. Among the sequela?, atrophy of the tes- 
ticle sometimes occurs from injury to the vas, and Otis relates a case 
in which semen escaped from a fistula located near the tuberosity of 
the ischium for some time. 

The treatment of gunshot of the cord consists in arrest of hemor- 
rhage and a clean dressing. 

Wounds of the Scrotum. — Gunshot wounds of the scrotum are 
seldom attended with much pain or danger. The contractile fibers 
of the dartos close the wounds so readily that wounds by reduced-cali- 
ber bullets are sometimes overlooked. This was particularly notice- 
able in two cases at Santiago. Otis mentions several cases of lodged 



300 GUNSHOT WOUNDS 

balls in the scrotum, the missiles having made their way thither from 
distant parts. 

The treatment consists in strict antiseptic management because of 
the tendency to infection. The appearance of the latter calls for 
free incisions and thorough drainage. 



CHAPTER X 

Injuries to Blood-vessels and the Nature of their Lesions; 
Results of Injury to the Blood-vessels; Traumatic Aneu- 
rysms; Aneurysmal Varix and Varicose (Arterio-venous) 
Aneurysm; Injury to Peripheral Nerves. 

Injury to blood-vessels as pointed out while referring to hemorrhage 
as a symptom of gunshot wounds has changed as to frequency, and also 
as to the nature of the lesion, with the change of armament. The 
vessels were wont to evade the pressure exerted by the low velocity 
round lead bullets of the old armament. As greater velocity was 
conferred on the projectiles, and as their shape became elongated, the 
tendency to escape injury on the part of the vessels was not so marked. 
The change that brought about the most characteristic results was 
coincident with the use of reduced-caliber bullets. The latter pass 
through the tissues so rapidly when animated by their greater velocity 
that the vessels have no time to be pushed aside. They either suffer 
(a) contusion, (b) partial or (c) complete division. 

(a) Contusion of an artery includes any degree of injury which 
does not open the lumen. A contusion may consist of a slight trau- 
matism involving laceration of tissues in the coats of the vessel with 
escape of blood from capillaries that infiltrate surrounding tissues, or the 
injury may be more severe, ending in necrosis of the coats of the vessel 
later. Bullets or larger missiles, moving at low velocity, when strik- 
ing at a tangent, may cause laceration of the inner and middle coats of 
the vessel, without injury to the outer coat. Injury of a minor kind 
will heal without subsequent symptoms as a rule, or there may follow 
a thrombosis, at the point of impact, leading to obliteration of the 
lumen. 

In severe contusion necrosis of the damaged part of the vessel may 
end in rupture, an occurrence which is common when sepsis has gained 
access to the injured part. In that event secondary hemorrhage will 
take place in ten to fifteen days from the receipt of the injury. Again, 
as a consequence of the lesion stated, a traumatic aneurysm may 
appear. 

301 



302 GUNSHOT WOUNDS 

Among the ultimate or later effects of injury to neighboring tissues, 
a vessel may suffer contraction by pressure or traction from scar tissue. 
The volume of the pulse below the seat of injury may thereby be per- 
ceptibly diminished, or an audible murmur may be found at the point 
where the vessel is compressed. 

(b) Partial division of an artery may occur from a displaced splinter 
of bone, a fragment of shell, a deformed bullet with sharp angles, or 
fragments thereof. The high-velocity small-bore bullet may cut 
away a notch in a vessel by striking it on the side, or in the case of 
vessels larger than its own caliber when it makes a regular impact in 
the middle of the vessel it inflicts two circular openings in the opposite 
walls of the vessel. 

(c) Complete division of an artery is followed by loss of pulsation 
in the distal portion of the vessel if the collateral circulation is deficient. 
If anastomosis is free it will reappear later. 

Wounds of veins are met with, and they are very similar to those 
of arteries. 

The results of injury to vessels are thrombosis and obliteration, 
and the various forms of hemorrhage to which we have already re- 
ferred. There now remain for consideration, traumatic aneurysms, 
and arterio-venous aneurysms. 

Traumatic Aneurysms. — Aneurysms as a result of trauma from 
gunshot have a far-reaching importance to-day as compared to former 
times. As an example, we may state that before the Spanish- American 
and Anglo-Boer Wars, traumatic aneurysms of the arterio-venous type 
were mostly seen in civil hospitals from stab wounds, injuries by 
machinery, and as a result of accident from the operation of venesec- 
tion at the bend of the elbow in the days of blood letting. The expe- 
rience of recent campaigns brings out the fact that surgeons now look 
to military instead of civil practice for the study of all forms of trau- 
matic aneurysm, and that what was once a comparatively unknown 
trauma in military practice has become one of the distinct features of 
war wounds by the new armament. 

Aneurysm as a result of trauma by gunshot occurred in seventy- 
four cases in the Civil War and forty-four cases in the Franco-German 
War, its appearance being one case for every 2000 wounded in the 
latter. While these figures represent the frequency of occurrence in 
former campaigns, a single observer in the Boer War like Graf found 
4 per cent, of his wounded suffering from some form of traumatic 
aneurysm. 



INJURY TO BLOOD-VESSELS AND NATURE OF THE LESIONS 303 

The frequency of blood-vessel injuries was apparent to us at San- 
tiago where out of 1400 wounded we observed five cases of gangrene as 
a result of vessel injuries which required amputation, one injury to the 
subclavian artery, two cases of ligation of the brachial and two of the 
femoral for diffuse aneurysm, and one case of arterio- venous communica- 
tion between the femoral artery and vein. 

Follenfant relates that the Russian Surgeon Bornhaupt out of 
3600 wounded at Kharbine operated five times on vessels of the extrem- 
ities for aneurysm, nine times for arterio-venous communications and 
that there were four cases of aneurysms cured following a period of 
rest. 

Two varieties of traumatic aneurysm are recognized, viz., the 
diffuse and the circumscribed. 

Diffuse traumatic aneurysm is due to persistent hemorrhage from 
an artery. The blood is effused into the surrounding tissues and the 
resulting lesion is more properly speaking a hematoma. This form of 
aneurysm, and the circumscribed variety also, are very common as a 
result of wounds from the reduced-caliber projectiles. They do not 
result so frequently from lead bullets, unless the latter have acquired 
a cutting edge from deformation. We stated under the subject of 
hemorrhage in the chapter on the Symptoms of Gunshot Wounds that 
free external hemorrhage was not of frequent occurrence with lesion 
of the larger vessels of the extremities and neck, because of the narrow 
track of the modern bullet. The narrow track is readily closed by a 
change of alignment of the apertures in the different layers of muscle, 
intermuscular septa and other soft parts. The occluded track arrests 
the external hemorrhage which would otherwise occur, and the result 
is free bleeding in the tissues which are dissected by the blood pressure 
causing considerable tension, interference to the venous circulation, 
and rise of temperature from absorption of fibrin ferment. Discolora- 
tion is present if the blood is near the surface. There may be fluctua- 
tion, loss of pulse and edema. 

The hemorrhage generally continues from the time of injury, but 
the symptoms attending its presence are not manifest for some days. 
When a bullet has grazed an artery the remaining coats may not give 
way at once. In such a case the appearance of the aneurysm will not 
show itself under ten days to three weeks. 

Treatment. — The indications for treatment of this form of traumatic 
aneurysm are similar to those for external primary hemorrhage. In 
the case of injury to smaller vessels or when the indications point to 



304 



GUNSHOT WOUNDS 



cessation of hemorrhage, active interference should be withheld. Such 
cases generally go on to speedy recovery by keeping the parts at rest. 
If the bleeding persists as shown by increased tension, the tumor should 
be laid open, the clots turned out and the artery tied above and below 
the seat of injury. When this cannot be done proximal ligature to the 
bleeding vessels should be practised, but in all such cases the incision 
in the tumor should still be practised and the cavity cleansed of clots 
to relieve pressure, otherwise gangrene may supervene from interfer- 
ence with the circulation below. The value of the foregoing methods 





Fig. 124. — Traumatic aneurysm radial 
artery from gun-shot wound by reduced 
caliber rifle bullet in the Russo-Japanese 
War. Treated by ligation and dissection 
of sac, discharged cured. Base Hospital, 
Heroshima, Dr. Tanaka, I. J. Army, Chief 
Surgeon. 



Fig. 125. — Traumatic aneurysm of right 
brachial artery from gun-shot wound by re- 
duced caliber bullet in Russo-Japanese War. 
Treated by ligation and dissection of sac. Dis- 
charged cured. Base Hospital, Heroshima, Dr. 
Tanaka, I. J. Army, Chief Surgeon. 



of treatment was well exhibited in the Anglo-Boer War. "Of forty- 
five cases reported in detail, direct ligature was done in twenty-seven, 

with no death In ten of these cases the vein 

had also to be tied. Proximal ligature was done in sixteen cases, with 
removal of the clot by a separate incision in two of the cases. None 
of these cases died, and in only one gangrene occured, after ligature of 
the femoral artery" (Spencer). 



INJURY TO BLOOD-VESSELS AND NATURE OF THE LESIONS 



305 



Direct incision and ligature of the vessel at the point of injury 
was practised very successfully also by the surgeons in the Manchurian 
campaign who generally deferred operation, whenever possible, until 
after healing of the external wound to avoid the complications which 
might arise from infection. The latter was a frequent attendant in 
vessel wounds by shrapnel balls, and but seldom noted in wounds by 
jacketed rifle projectiles. 

Circumscribed traumatic aneurysms are the result of small openings 
made in vessels at the seat of a previous injury. The vessels are gen- 
erally surrounded by dense tissues like the popliteal and the tumor is of 




Fig. 126. — Traumatic aneurysm of brachial artery from reduced caliber rifle bullet, in the 
Russo-Japanese War, treated by ligation and dissection of sac. Discharged cured. Base Hospital 
Heroshima, Dr. Tanaka, I. J. Army, Chief Surgeon. 

small size, seldom larger than a hen's egg and very firm. They are of 
a less serious nature than the diffuse variety of aneurysm just described. 
They have the expansile pulsation and bruit of spontaneous aneurysms. 
The treatment is rest, under which the majority show a tendency to 
contract and they occasionally disappear. The tendency, however, 
is toward gradual enlargement, and to rupture finally. The operative 
treatment is usually practised sooner or later, and this consists in 
direct ligation above and below the seat of injury and dissection of 
the sac. If this method is impracticable, ligation just above the seat 

20 



306 GUNSHOT WOUNDS 

of injury, Ariel's operation, or Hunter's operation should be prac- 
tised. Stevenson states that the majority of cases in the Boer War 
occurred in injuries to the popliteal artery and that the favorite 
operation was to place a ligature at the edge of the adductor magnus 
because it was less likely to cause gangrene than ligature of the femoral 
higher up. Here we have three (3) illustrations of traumatic aneu- 
rysms from the Manchurian campaign loaned by Dr. Louis Livingston 
Seaman. (Figs. 124, 125, 126.) 

The experience of surgeons in the great European War is rich in 
satisfactory management of all kinds of aneurysms by the various 
methods of treatment. 

Auvray (Bull, et Mem. Soc. de Chir. de Par. 1915, XLI, 851) gives 
his experiences in 15 cases of operation for aneurysm, 7 of which were 
arterial aneurysms, 7 arterio-venous and one diffuse. The arterial 
aneurysms were located as follows: 2 in the radial, 2 in the brachial, 
1 in the ulnar, and 1 in the superficial temporal, and the diffuse 
aneurysm was in the axilla. These aneurysms were extirpated in all 
cases. He never employs lateral suture in gunshot injury of a 
vessel because of the extent of the traumatism to the vessel wall 
although he has resorted to the method in aneurysm from stab wound 
of a vessel. An indispensable requirement of success is to expose the 
aneurysm very freely. In aneurysms of the limbs, the author recom- 
mends constriction to prevent loss of blood, in other locations he 
clamps the vessels as near as possible to the aneurysm. In removing 
the sac of an arterio-venous aneurysm in operable cases he takes the 
precaution to ligate the large venous and arterial trunks above and 
below. 

On the other hand Bier (Beitr. z. klin. Chir., 1915, XCVI, 556) 
believes that the best treatment is either lateral or transverse suture. 
He reported 102 operations for aneurysm at a congress of German 
military surgeons held at Brussels in 1915. The aneurysms were of 
recent date and the sacs were filled with old blood-clots. Forty-five 
of the cases were arterial and 56 arterio-venous in character. He 
recommends the use of Momburg's tube to control hemorrhage in 
aneurysms of the femoral and pelvic vessels. In 74 cases of suture of 
arteries, lateral suture was employed iri the majority of the cases, 
while transverse suture was employed in but 3 cases. Bier claims that 
lateral suture is a simple operation in arterial aneurysm. 

Suture of vessels is contraindicated in infected aneurysms. Many 
of Bier's cases recovered spontaneously under rest and pressure. There 



INJURY TO BLOOD-VESSELS AND NATURE OF THE LESIONS 307 

were 8 deaths among his operated cases, four of them being in 
aneurysms of the subclavian artery. All the others recovered. 

Zahradnicky (Die Behandlung der unechten Aneurysmen; Wien. 
Klin. Wochnschr., 1915, XXVIII, 999) presents the literature of aneu- 
rysm during the Turko-Balkan War of 1912 and '13, and the present 
European War in a most interesting way. He presents a table with 
results of operations by different methods in 425 cases. The cases 
were reported by 45 different authors. Ligation was employed in 242 
cases while 182 were treated by vessel suture. Gangrene developed 
in 11.5 per cent, of the former, necessitating amputation in every case. 
Gangrene developed in but 3.7 per cent, out of 182 cases treated by 
suture. The mortality after the two methods was about the same — 
7.4 and 7.1 per cent. It is thus seen that gangrene is 3 times more 
frequent after ligation than it is after suture, and the author points 
out that it would be much less if the advice of experienced surgeons 
were followed : to operate early before adhesions have formed and when 
there is less tendency to thrombosis. 

Zahradnicky gives his individual experience in 52 cases. Three cases 
recovered spontaneously, the remainder were subjected to operation 
as follows : 28 were treated by ligation, 1 by plication of the sac, and 
20 by vessel suture. Six of the cases were treated by ligation, 6 ended 
in gangrene and amputation, 1 in superficial gangrene, and 4 died 
of sepsis. Among the 20 cases treated by vessel suture, but 2 ended 
in gangrene or 14.2 per cent, as compared to 21.4 per cent, after liga- 
tion, showing again that gangrene is more frequent after ligation than 
after vessel suture. 

The author states that ligation should be reserved for severe cases 
of sepsis or anemia or for cases in which operation is deemed neces- 
sary to save life, and also in cases where the collateral circulation is 
already established and suture has become unnecessary. When a con- 
siderable length of vessel has been sacrificed, transplantation of a 
piece of vein becomes necessary. The operation is difficult, but very 
successful in experienced hands. Those not familiar with the new 
surgery of blood vessels should practice vessel suture and vein trans- 
plantation on lower animals. No special instruments are required. 

We may state that Carrel uses the finest silk, sterilized in liquid 
vaseline and the finest sewing needles. The vessel is clamped above 
and below temporarily with forceps covered with rubber that will not 
injure the vessel. The blood which issues from the ends of the vessel 
is washed away with normal saline. The adventitia is dissected 



308 GUNSHOT WOUNDS 

back and the edges of the vessel to be sutured are touched with liquid 
vaseline. Care should be taken not to catch the edges of the vessel 
to be sutured with forceps lest they be contused thereby. The tissue 
should be caught by the point of the needle and the latter passed 
straight through. In cases of partial division of an artery, continuous 
suture is employed taking all the coats except the stripped adventitia. 
A guide suture at each end of the incised vessel will produce eversion 
of the intima on slight traction and thereby facilitate the operation. 
When the vessel is cut transversely, three equidistant guide sutures 
are passed through the ends of the vessels and tied so as to evaginate 
the intima, and the sutures, which should be about one-fifteenth of an 
inch apart, are applied continuously as before. 

Fritz Lotsch (Beitr. z. klin. Chir., 1914, XCI, 175) who has had 
extensive experience in gunshot injuries of blood vessels in the Turko- 
Balkan War has written his conclusions which are given in part as 
follows: (1) In most cases of aneurysm there is formation of a " silent 
hematoma" which exhibits pulsation in a few days and which results 
in a traumatic aneurysm. 

(2) Injury near large vessels should be carefully immobilized lest 
thrombosis and embolism occur. 

(3) " Silent hematomas" should be transported under the best 
transport facilities and only when they have been securely immo- 
bilized. The danger of hemorrhage should be noted on the diagnosis 
tag. 

(4) Under proper fixation and slight compression many aneurysms 
from gunshot heal without further treatment. Primary ligation is not 
in order unless there is danger of pressure gangrene, and for cases of 
suppuration. 

(5) Ligations should not be undertaken at the front except in cases 
of urgent necessity. Operations for aneurysm should be performed 
in field hospitals, when the collateral circulation has been established, 
and when excision of the aneurysmal sac may be done after ligation of 
the afferent and efferent vessels, under the same environment as in 
civil hospitals. 

(6) Primary suture of vessels is impossible at dressing stations. 
Such an operation should be delayed until favorable environments 
obtain. 

Arterio -venous Aneurysms. — Communication between an artery 
and vein as a result of trauma is known under the designation of arterio- 
venous aneurysm. The communication is effected in two ways (1) 



INJURY TO BLOOD-VESSELS AND NATURE OF THE LESIONS 309 

aneurysmal varix — in which the communication is direct, the artery 
and vein being in contact, (2) varicose aneurysm — when a partial or 
complete sac exists between the two vessels through which blood flows 
from one to the other. These communications are more or less charac- 
teristic of gunshot wounds. They are seldom met with as a result 
of the traumata usually encountered in civil practice, except as 
the result of stab or punctured wounds. They were also noted in the 
days of the old-time operation of venesection at the bend of the elbow. 
In military practice they have become more frequent as a result of 
reduction in the caliber of the military rifle, and military surgeons 
report an increasing number of instances among the wounded in recent 
campaigns. The .30-caliber jacketed bullet may pass the line of an 
artery and vein lying adjacent to one another, notching both, or it 
may pass between the two vessels, notching their contiguous surfaces. 
The resulting injury later develops into an aneurysmal varix or a 
varicose aneurysm. 

(1) Aneurysmal varix is less common than varicose aneurysm, but 
it is more frequently met with in those vessels which lie adjacent or 
closely apposed and firmly held together like the popliteal vessels or 
the femoral vessels in Hunter's canal. An aneurysmal varix is very 
apt to occur also as a result of pressure surgically applied to stay the 
flow of blood. In either case the amount of effused blood is limited, 
it is later absorbed, and the communication between the vessels remains 
with no intervening sac. An aneurysmal varix may also follow after 
the temporary presence of a sac, when the latter shows a tendency to 
diminish gradually, and finally to disappear with no semblance of a 
tumor remaining, so that the case which was originally an arterio- 
venous aneurysm is thereby converted into an aneurysmal varix. 

Symptoms. — Three or four days after the receipt of the injury and 
often later, a thrill and murmur which are constantly present make 
their appearance. The thrill is more distinct, with slight palpitation; 
it extends over a considerable area and when the vein is exposed, dur- 
ing an operation, the pulsations of the artery convey visible vibrations 
to its walls. Auscultation reveals a murmur which is loud and said 
to be audible at a short distance. If the varix is in the neck, the mur- 
mur is distinctly annoying to the patient at night when he lies on the 
injured side. The tendency is toward dilatation of the artery immedi- 
ately above the point of communication with the vein. 

The prognosis in aneurysmal varix is generally favorable. There 
is a frequent tendency to rapid pulse from 100 to 140 per minute which 



310 GUNSHOT WOUNDS 

can be lessened by a quiet mode of living. The dilated condition of 
the arteries above the communication with the vein which develops 
in the course of years was well shown in the case of Captain Theodore 
Mosher of the 22nd U. S. Infantry, who was shot by a Mauser bullet 
at Santiago, July 1, 1898. The bullet entered the left thigh in the 
middle of Scarpa's triangle and emerged at the level of, and 1 inch pos- 
terior to, the great trochanter of the corresponding side. External 
hemorrhage was severe at first and the patient lost consciousness. 
Wounds healed by primary intention in two weeks. When examined 
for the second time by Doctor Senn on or about July 15, the patient 
was anemic. There was a pulsating swelling in Scarpa's space directly 
under the wound, the characteristic thrill and machinery murmur 
extended some distance above and below the point of communi- 
cation between the artery and vein. The officer convalesced very 
slowly. He was retired from active service and placed on duty with 
the District National Guard at Washington where he resided till 
the time of his death in 1911, thirteen years after the receipt of the 
injury. 

Doctor Thomas N. McLaughlin, his attending physician, states 
that there was marked disturbance to his circulation in later years. 
The pulse at the wrist was fast at times, slow at others and nearly 
always irregular. The dilated arteries extended from the bifurcation 
of the common iliac to the lower third of the thigh. The disturbed 
circulation brought on portal congestion and enlargement of the liver 
from passive congestion, the liver margin extending as low as the 
umbilicus. The leg was edematous from pressure. There were pain, 
strong pulsation, and loss of sleep which brought on nervous strain. 
In 1906 the dilated condition of the arteries was very much increased, 
the pain and incapacity for physical exercise became more marked. 
Cardiac hypertrophy, valvular lesion, albuminuria and anasarca were 
noted toward the last. 

The treatment of aneurysmal varix will be included under that of 
varicose aneurysm as the measures of relief are quite similar for both 
conditions. 

Varicose Aneurysm. — As stated already this is the more frequent 
of the two forms of arterio-venous communications. The forma- 
tion of a sac between the two apertures in the injured vessels is favored 
by the anatomical relations of the vessels, and the amount of blood 
effused. The formation of a sac more often occurs between vessels 
that lie in a bed of loose areolar tissue as in Scarpa's triangle or the 



IN* JURY TO BLOOD-VESSELS AND NATURE OF THE LESIONS 311 

subclavian vessels. The separated condition of the vessels favors a 
greater amount of extravasation of blood. The latter becomes circum- 
scribed, and forms a tumor which later becomes the sac of a varicose 
aneurysm. It is likely that more or less extravasation is present in 
all arterio-venous communications. The tendency is for the smaller 
amounts of effused blood to become absorbed before a sac is formed, 
while larger extravasations, being only absorbed in part, resolve them- 
selves into the formation of a sac. Some of the operators in recent 
wars claim that in the majority of the lesions showing arterio-venous 
communications there is evidence of a well-formed sac or the remains 
of a pre-existing sac, showing that the natural outcome of the simul- 
taneous wounding of the two vessels is toward the formation of vari- 
cose aneurysm in the early history of the majority of the cases. 

Symptoms. — The pulsation, thrill and bruit noted as symptoms 
of aneurysmal varix are present in varicose aneurysm. In many 
cases the thrill is present only after the disappearance of the primary 
swelling which follows the injury. Makins states that in some cases 
of arterio-venous aneurysms observed in South Africa in the fore- 
arm, calf, and popliteal space the thrill was discovered by accident 
some weeks after the injury, after no serious vascular lesion had been 
suspected. 

The murmur common to all these injuries is often referred to under 
the name of " machinery murmur," it is widely distributed, but the 
distinguishing feature between varicose aneurysm and aneurysmal 
varix is the presence of a tumor, showing expansile pulsation. The 
latter is often absent in the early history on account of blocking of 
the artery, and also in large tumors before they have become circum- 
scribed. In this stage the blood is diffused about the tissues, there is 
no definite cavity and the conditions are not favorable to the transmis- 
sion of the wave as they become later with the presence of definite 
walls. 

The prognosis is far less favorable than that of aneurysmal varix. 
The dangers which beset the patient are the same as those of spontane- 
ous aneurysm. Once a tumor has formed the usual tendency is for it 
to enlarge just as it does in aneurysm from other causes. 

Treatment. — For both aneurysmal varix and varicose aneurysm the 
first indication is rest in bed, which should be prolonged in accordance 
with the progress noted. In cases of varicose aneurysm rest in bed as 
stated may result in converting the case into one of aneurysmal varix, 
a condition far less serious. If the vessels implicated are in a limb, a 



312 GUNSHOT WOUNDS 

splint of plaster of Paris, in addition to rest, will insure absolute quiet. 
As to the advisability for operative treatment this depends upon the 
vessels affected and the amount of disturbance present. The vessels 
of the upper extremity offer the best results for operative treatment, 
and this is especially true of the brachial and its accompanying vessels. 
The vessels of the forearm frequently show no serious symptoms so 
that operation there is not always necessary. The femoral and pop- 
liteal vessels should not be operated upon except in cases of necessity. 
In the leg the tibial vessels may be operated upon with safety. 

The most effective operation for both forms of arterio-venous com- 
munications is ligation of the artery above and below and as near as 
possible to the point of communication without interference to the 
vein. This operation is nearly always practicable in the limbs and it 
is especially adapted to the relief of aneurysmal varix. Proximal liga- 
ture should be avoided when possible as it is apt to be attended with 
gangrene, although Stevenson states that in several operations where 
proximal ligature was tried in South Africa, gangrene did not appear. 

Varicose aneurysms usually show a tendency to enlarge and eventu- 
ally to rupture, in which case the indications are the same as for 
traumatic aneurysms of the diffused kind. Ligation above and below 
the point of communication in varicose aneurysms is the ideal opera- 
tion in small tumors. The ligature should be applied in sound tissue 
as close as possible to the sac. 

In arterio-venous communications involving the large vessels of 
the neck operation should be avoided until rendered necessary by the 
increasing effects of pressure from dilated vessels or extension of the 
sac, in the case of a varicose aneurysm. Here the most suitable and 
most generally the only operation available is ligature of the main 
trunk on the proximal side of the sac. The sac consolidates and disap- 
pears in the course of a few months. The thrill and slight pulsations 
remain in some cases with no tendency to increase. 

Bier 1 who is a firm believer in the method of vessel suture for all 
kinds of aneurysms, reported 36 operations performed since the com- 
mencement of the present European War for arterio-venous aneurysm. 
The operation for arterio-venous communications is more difficult than 
it is for aneurysm alone. In all instances, he resected a piece of artery 
and employed end to end transverse suture. Transplantation of a 
piece of vein to fill the gap as recommended by some authors was not 
found necessary. Circular suture is an easy operation; intima is 

1 Op. cit. 



GUNSHOT INJURIES OF PERIPHERAL NERVE TRUNKS 313 

applied to intima and a continuous suture is then inserted through the 
remaining coats. Small arteries are ligated. When a large vein runs 
through an infected aneurysm it should be ligated in two places and 
resected. 

Treatment by reconstruction of the vessels is preferable when im- 
portant vessels are involved. The bleeding should be under good 
control; the vessels should be well exposed and a free incision should 
be made. 

When a sac is present (arterio-venous aneurysm) it should be ex- 
cised with as little impairment of the lumen of the vessels as possible. 
One may now proceed by ligating the artery above and below if lateral 
suture is not practicable, and the operation is then completed by re- 
pairing the vein. When the sac has been removed, and the vessels 
have been entirely separated, if one finds a small opening, the artery 
and vein may be closed by Carrel's method. The same procedure is 
observed in cases without a sac (aneurysmal varix) provided the 
lateral wounds are not so extensive as to cause undue narrowing after 
repair has been accomplished. When the vessels show much laceration 
they should be repaired by excision of the lacerated segment and end- 
to-end suture employed ; or the vessels may be ligated above and below 
the injury when the location of the aneurysm and the function of 
vessels permit. 

GUNSHOT INJURIES OF PERIPHERAL NERVE TRUNKS 

Injuries to nerves by gunshot have assumed additional interest 
with the use of the improved armament in modern wars. Except in 
the case of injuries implicating the great nerve centers, wounds of this 
class have been attended by a very small percentage of mortality. 
Gunshot injuries to nerves were formerly recognized as a group which 
often resulted in complete and permanent disability, accompanied by 
much suffering and only occasionally amenable to treatment. Doubt- 
less much of the protracted suffering and hopeless condition arose from 
pressure symptoms as a result of lodged missiles, callus, and cicatricial 
bands in old infected wounds. Hopeless paralyses came from lack of 
our present knowledge of nerve suture. 

The character of the wounds from the soft, larger-caliber lead bul- 
lets also added to the frequency of traumatism like severe contusion, 
and partial or complete division of nerve trunks. The same lesions also 
occur from the military rifle projectiles of the present day; the contu- 



314 GUNSHOT WOUNDS 

sions are neither so extensive nor so frequent, but instead a large class 
of disabling wounds as a result of vibratory concussion on nerve trunks 
has figured prominently among nerve injuries in recent wars. 

Concussion of individual nerves is almost entirely identified with 
the effects of the high-power rifle bullet and the degree of concussion 
noted is closely related to the velocity of the bullet at the time of 
impact. As pointed out in transverse lesions of the spinal cord from 
the same cause it is not necessary that the projectile should come in 
direct contact with the nerve substance. Temporary and complete 
loss of function of an adjoining nerve is common enough now, after 
fracture of the shaft of a long bone. The amount of concussion which 
the nerve trunk suffers, and the disabling effects therefrom, are pro- 
portional to the resistance of the bone hit and the velocity of the bullet. 
Thus the effects are more frequently noted after a high-velocity bullet 
encounters the compact substance of the shaft than we find in cases 
where the bullet traverses the cancellous end of a bone. But concus- 
sion of a nerve from the vibratory impulse caused by the bullet travers- 
ing soft tissues alone is also met with, showing that the transmitted 
energy from the bullet alone is sufficient to produce the lesion that we 
call nerve concussion. Such a lesion may be accompanied by all the 
symptoms of complete section, which may persist for many months. 

The nature of the anatomical lesion is not demonstrable micro- 
scopically nor macroscopically. All we know is that a section of the 
affected nerve is for the time being completely destroyed as a conductor 
of impulses, the connective tissue remaining intact. In discussing 
gunshot wounds of the neck we cited cases of nerve lesion from concus- 
sion observed at Santiago, to which the reader is referred. 

We are specially indebted to Mr. Makins and Col. Sylvester 1 
for the painstaking way in which they have described their rich expe- 
rience in nerve lesions during the Anglo-Boer War. Cases which were 
once more or less obscure are now readily understood by the explana- 
tion of the transmission of vibratory concussion or the dispersion of 
the bullet's energy. Cases of this kind were duly appreciated by the 
older writers and especially by Acting Assistant Surgeons Mitchell, 
Morehouse and Keen, U. S. A., and quoted by Otis. In writing of 
such injuries to the brachial plexus, for instance, they attributed the 
paralysis to "brief compression of the (nerve) trunks during the move- 
ment of the missile or to agitation of the nerves through the tearing of 

1 Gunshot Injuries of Peripheral Nerves in Reports of Surgical cases in South 
African War by Lt.-Col. Sylvester, R.A.M.C. (Stevenson.) 



GUNSHOT INJURIES OF PERIPHERAL NERVE TRUNKS 315 

tissues more or less remote." In other parts of their work they often 
use the word " commotion" to convey the meaning of vibration as a re- 
sult of the bullet's energy. Such cases were not then so frequent as 
they are now because of the lower velocity and energy of the bullets 
then in use. 

Symptoms of Concussion. — Among the most common symptoms 
will be found partial or complete loss of function which includes loss 
of sensation only or loss of both sensation and motion. The symp- 
toms are temporary in character, lasting seldom more than a week 
or ten days. In slight cases there is complete or partial anesthesia of 
a transient character in the skin distribution of the nerve accompanied 
by tingling sensations. In the more severe cases the loss of motion 
and sensation is absolute as one always finds in the complete division 
of a nerve, with subsequent wasting of muscles and the usual trophic 
changes in the skin, nails, etc. Though seemingly hopeless, these 
cases, whether complete nerve degeneration has been established or 
not, undergo the process of regeneration, during which sensation is 
the first to return, to be followed by motion later on. 

Contusion. — This traumatism is produced by slight contact of the 
bullet, secondary missiles or spicula of bone with the nerve proper, 
although the presence of any anatomical lesion is not always very 
definite. The symptoms of contusion are often attended with slight 
hemorrhage among the nerve fibers the presence of which is suggested 
by signs of irritation, like pain and hyperesthesia. Differentiation 
between concussion and contusion is often difficult. Generally, con- 
tusion is a much more serious condition than concussion. 

Symptoms. — The symptoms of contusion, in so far as motion and 
sensation are concerned, resemble those of division of a nerve, but they 
are not so complete. There is still reaction of the muscles to the 
stimulus of electricity but it is diminished. Some of the muscles to 
which the affected nerve is distributed may exhibit complete paralysis, 
while others still respond to the f aradic current. The loss of sensation 
is also irregular, occurring in patches. Trophic changes such as red- 
ness of the skin, eczema, club nails, pain, stiffness, polished skin, loss 
of hair, hyperesthesia and burning sensations may appear. The 
muscles may atrophy and become flaccid. 

Recovery is always to be expected. This may be deferred for 
months, and then in cases of more or less complete paralysis recovery 
of wasted muscles will take place suddenly. Sensation, as noted in 



316 GUNSHOT WOUNDS 

cases of concussion, usually precedes the reappearance of motion, and 
its return is regarded as a valuable diagnostic and prognostic sign. 

Partial Division. — This is one of the common traumatisms from 
gunshot. According to the reporters from the Manchurian campaign 
the large majority of such cases were noted as a result of injury from 
the jacketed bullets. Fischer states that Hashimoto found 77 per cent, 
and Schaefer 90.6 per cent, of their cases as a result of wounds by 
these projectiles. In most of the cases the larger nerves were slit by 
the bullets, but bullets were also known to perforate nerves smaller 
than their own caliber. Slits were commonly seen in nerves of 3 mm. 
in diameter and over. Notching was more common than perforations. 

Symptoms. — In partial lesions response to electrical stimulation 
is incomplete save in those cases attended with concussion, but the 
transient nature of the latter is soon revealed by return of sensation 
to electrical stimulation. The loss of sensation and motion is not pro- 
longed in the distribution of those fibers which escaped division.' ' 

Complete Division. — This traumatism is commonly observed in 
the smaller nerves. It cannot well occur in the larger nerves like the 
great sciatic by the small jacketed bullet except as a result of injury 
from a deformed bullet and from shots when the bullet is travelling at 
a tangent to its line of flight. In such cases the largest nerves suffer 
complete section. The extent of nerve involvement depends upon the 
angle of impact. When the bullet traverses the nerve at right angles 
the loss of nerve substance corresponds to the caliber of the projectile 
and when the course of the nerve is hit obliquely an inch or more of 
nerve tissue may be involved. 

Symptoms. — Complete division of a nerve is followed by loss of 
sensation and motion in its distribution. In a few days the muscles 
fail to react to the faradic current and this is followed soon thereafter 
by the customary signs pertaining to reaction of degeneration and the 
well-known trophic changes in the skin, hair, nails, etc. 

A positive diagnosis is to be made if there is total loss of response 
to electric stimulus by the nerve trunk, or the diagnosis is equally 
certain in the case of nerves superficially placed if the bulbous end can 
be identified by touch. 

Treatment. — The treatment of injury to peripheral nerves is ex- 
pectant and operative. 

In the expectant treatment we employ warmth and complete rest 
by means of a splint for at least one month. At the end of this time 
if pain and tenderness have sufficiently passed away the use of the 



GUNSHOT INJURIES OF PERIPHERAL NERVE TRUNKS 317 

galvanic current, gentle massage and passive movement of joints should 
be commenced. Morphia is to be used to subdue pain only when 
absolutely necessary. Every precaution to prevent infection of the 
wound should be practised from the beginning as suppuration pro- 
longs recovery and adds to complications like neuritis, and pain from 
subsequent contraction in cicatricial tissue. 

The treatment by operation may be divided into (1) immediate, 
(2) intermediate and (3) operation for secondary involvement. 

(1) Immediate operation is practised when for other reasons dur- 
ing an operation or exploration a divided nerve trunk comes into view 
in which case it should be sutured before the wound is finally closed. 

(2) Intermediate operation should not be undertaken before the 
end of two months or more because the necessity for operation is often 
not revealed until this lapse of time. Operation is imperative at 
about this time when the nerve trunk has been completely divided, 
but the establishment of the presence of such an injury can only be 
made by the symptoms that develop, and these, as we have already 
pointed out, are so entirely simulated by the symptoms of concussion, 
contusion, or a combination of both, that it is always in order to wait 
a reasonable time for the signs of recovery that are sure to appear 
after these minor lesions. The recovery that follows the latter takes 
place without operation. The process of repair in concussion or con- 
tusion is often prolonged, since the nerve undergoes degeneration and 
subsequent regeneration of the distal end before signs of returning 
function are noted. Experience teaches that nothing is lost by delay 
in operating for division of a nerve trunk. Premature operations have 
often been undertaken only to find that the nerve trunk was intact 
and apparently normal such as we always expect to find in concussion 
with or without contusion. 

In the case of a divided nerve operation should only be undertaken 
after the lapse of the time mentioned and after all reaction to faradiza- 
tion has disappeared, when the muscles continue to waste and the 
trophic changes mentioned are progressing. 

When the opportunity arises to suture a nerve at the time of the 
primary dressing, this should be done under strict asepsis. Suturing 
is best done at this time with a small round sewing needle, threaded 
with fine chromicized catgut or silk suture, through the sheath of the 
nerve, employing the mattress stitch or Lembert suture. The ends 
of the nerve should be brought snug together to promote restoration 
of function. When the whole of the nerve trunk cannot be sewed 



318 GUNSHOT WOUNDS 

together the parts or filaments that can be identified should be care- 
fully sutured. When loss of substance has occurred stretching of the 
divided ends to secure approximation is permissible. When the 
loss has been considerable, grafting the distal end to an adjoining nerve 
may be practised. The limb should be fixed with a plaster-of-Paris 
splint for several weeks in a position to avoid traction on the ends of 
the divided nerve. Later prolonged treatment by massage, elec- 
tricity and gymnastics should be employed. The bulbous ends may 
be split and turned toward each other to fill the gap, or in place of this 
method the usual forms of splicing known to surgeons may be employed. 
(3) Operations for Secondary Involvement. — Operation is often 
necessary when a nerve becomes painful and its function is otherwise 
interfered with by pressure in scar tissue or in callus. In such a case 
the nerve should be exposed, freed from all adhesions, and stretched. 
It sometimes becomes necessary to stretch nerves afflicted with neu- 
ralgia that were only grazed primarily by bullets, with no apparent 
lesion other than possible traction from adjoining cicatricial tissue. 



CHAPTER XI 

Gunshot Wounds of Joints 

The gravity of wounds of Ijae larger joints until recent years ranked 
next to those of the large body cavities. The present-day beneficent 
results in joint wounds by gunshot are far more striking to the military 
surgeon than they are to the civilian practitioner. The latter has 
noted marked improvement as a result of the introduction of anti- 
sepsis, while the former has in addition to antisepsis noted marked 
beneficence from the use of the reduced-caliber projectiles as well. 

The happy results which arise from the use of the jacketed bullets 
were foretold by all the experimenters before the use of these bullets 
was undertaken in warfare. Those who were concerned in testing 
the reduced-caliber rifles in the beginning observed the striking change 
in the character of joint wounds especially. Since the destructive 
effects in tissues, as often stated already, are proportional to the velocity 
of the bullet, its sectional area, and the resistance which it encounters 
on impact, we found that the spongy nature of the epiphyseal ends 
of bones offer a minimum amount of resistance, and that the epiphyses 
except in the very proximal ranges, were perforated without fissure, 
in the same manner that soft tissues generally are perforated. In 
other words the tendency of the armored bullet, in passing through 
the joint ends of bones, is to make a clean-cut perforation without 
fracture and the chances of complete recovery, with the use of a simple 
dressing and subsequent immobilization, is assured in nearly all cases. 

The lesion inflicted in the joint ends of bone by the large-caliber 
lead bullet in former wars favored the development of sepsis to a 
marked degree. The soft lead bullet was prone to lodge and it gen- 
erally deformed on impact against the bony structures, thereby 
increasing its sectional area. The amount of laceration of the soft 
parts attendant upon the displacement of bone fragments caused ex- 
tensive hematomata about the cellular tissue, the synovial membrane, 
and joint attachments. The bone itself was fragmented and fissured 
so that the lesion in itself particularly augmented the development 
and spread of the infection that was invariably carried with the ball, 

319 



320 



GUNSHOT WOUNDS 



as well as that which was forced into the wound with particles of 
clothing and the integument. Such cases were invariably septic, 
and the mortality was correspondingly great. 

The changes that have been wrought in recent years from the use 
of antisepsis and the new armament are at once shown in the follow- 
ing tabular statements. 1 

PERCENTAGE MORTALITY FROM WOUNDS OF THE JOINTS IN FIVE 

WARS 



Joint 



American 
Civil 
War 



Franco- 
Prussian 



Japan- 
China 
(Haga) 



Spanish- 
American 



Anglo- 
Boer 
War 



Hip 

Knee. . . . 
Ankle . . . 
Shoulder 
Elbow . . . 
Wrist... 



84.7 
53.7 
26.9 
31.1 
9.4 
12.9 



71.8 
48.9 
24.0 
35.5 
21.2 
12.6 



100.0 
25.0 
0.0 
0.0 
0.0 
0.0 



0.0 
5.5 
0.0 
0.0 
0.0 
0.0 



0.5 
4.2 
0.0 
3.7 
2.0 
0.0 



CASES AND DEATHS IN EACH CLASS OF JOINT WOUNDS IN THREE 

RECENT WARS 



Joint 


Japan-China War 
(Haga) 


Spanish-American 

War and Philippine 

Insurrection 


Anglo-Boer War 




Number 


Deaths 


Number 


Deaths 


Number 


Deaths 


Hip 


1 

16 
4 
4 

16 
6 


1 
4 






3 

77 
26 

9 
44 

6 


1 

2 
2 
1 
1 



7 
95 

40 
27 
49 
10 


2 


Knee 

Ankle 

Shoulder 

Elbow 

Wrist 


4 

1 
1 



Total 

Mortality, per 
cent. 


47 


5 
10.6 


165 


7 
4.2 


228 


8 
3.5 



1 W. C. Borden, Lt.-Col. U. S. A., in Vol. II, Bryant and Buck American 
Practice of Surgery. 



GUNSHOT WOUNDS OF JOINTS 321 

In the Manchurian campaign Follenfant, quoting from the Khar- 
bine statistics of 1905, found 1382 gunshot injuries of joints with but 
seven deaths and seventy-two resections. It is safe to state that the 
latter were not from fractures caused by the reduced-caliber bullet 
but more likely shots from shell fragments or shrapnel. Projectiles 
from the latter sources still cause extensive fracture in the epiphyseal 
ends of bones, with tendency to suppuration. Surgical interference 
in the way of partial excision with drainage is to be practised in the 
large majority of such cases, in order to preserve life and limb. 

Vibration Synovitis. — Mr. Makins has called the attention of the 
profession to synovitis as a result of the vibratory force which shocks 
a joint by the dispersion of the energy of the high-power modern rifle 
bullet. In such cases he found a " considerable amount of synovial 
effusion into joints of limbs in which the articulation itself was prim- 
arily untouched. " He found these effusions also in cases where the 
soft parts alone had been traversed, in tissues near the knee-joint 
especially, and he attributes them to the shock of impact conveyed 
to the entire limb; but he found these effusions most generally after 
fracture of the diaphysis and notably so in the hip-, knee- and ankle- 
joints, and not so often in the joints of the upper extremity. The 
theory of vibratory synovitis is most tenable to us and one that will no 
doubt attract the attention of military surgeons very much hereafter. 

Gunshot wounds of joints are usually divided as follows: 

1. Lesion of joint without injury to osseous structures. 

2. Wounds of joint accompanied by lodged missile. 

3. Lesion of joint marked by grooving of the articular ends of 
bones. 

4. Perforation of articular ends across the joint. 

5. Comminution of articular ends of bones. 

(1) Lesion of Joint without Injury to Osseous Structures. — These 
were rare injuries with the use of the old armament. The capsule 
of the joint is opened by the bullet without inflicting injury to the bones 
entering into the formation of the joint. This is more apt to occur 
in the wounds of the knee. With the present-day military rifle 
bullet this occurrence is not infrequent. The ill effects are but slight, 
due principally to effusion of blood in the joint. There is little danger 
of infection. Rest on a splint is the only treatment required. 

(2) Wounds of Joints Accompanied by Lodged Missiles. — This 
form of injury was present in olden times with the use of low velocities. 
The U. S. Army Medical Museum has a rich collection of such cases 

21 



322 



GUNSHOT WOUNDS 



from our Civil War. Because of the superior velocity conferred on 
the high-power military rifle of the present day, lodged rifle projectiles 
in joints are now of rare occurrence in war. Wounds of this kind are 
still common from shrapnel and fragments of shells, and from pistol 
balls in civil practice. 

(3) Superficial Grooving of the Bones.— In these cases there is a 
superficial grooving, and although the joint is not so directly implicated, 
these wounds prove by far the most serious because of the great danger 
to infection which is inherent in the character of the wound. The 




Fig. 127. Fig. 128. 

Fig. 127.— Photograph in case of Corpl. H. C. S., Co. "F," 122nd N. Y., shot March 27, 1865. 
Globular head of femur is shattered by conoidal ball which remains lodged. Head of bone ex- 
cised at junction with neck. Acetabulum was involved. Died from peritonitis Apr. 8, 1865. 
No. 9821. A. M. M. collection. 

Fig. 128.— Pvt. J. R. Co. "C" 69th N. Y. Wounded March 25, 1865. Died of exhaustion 
Apr. 6, 1865. Conoidal ball entered anteriorly and lies lodged in great trochanter. A fissure 
6 inches long extends down the shaft from the point of lodgment. No. 98211, A. M. M. collection. 



entrance and exit wounds in the skin are generally oval since the bullet 
enters and leaves the skin at a tangent to the surface. This in itself 
invites the development of infection. The injury to the capsule is 
often marked by a superficial tear of some length as seen in the knee 
especially, with spicules of bone protruding. The synovial sac is 
naturally more extensively involved from a long narrow track made 



GUNSHOT WOUNDS OF JOINTS 323 

by the ball than it is when it suffers two direct perforating wounds. 
Movement of a joint so injured, a common occurrence in war, adds to 
the traumatism and to existing infection. Absolute fixation of a 
limb so injured should be practised at once. Wounds in the neighbor- 
hood of joints should all be treated as gutter wounds of the synovial 
membrane. 





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Fig. 129. — Pvt. M. J. 52nd N. Y. Photograph shows shattering of tibia into ankle-joint 
by conoidal bullet with long fissures extending in shaft. Shot at Chancellorsville, Mar 3, 1863. 
Amputation on fourth day after injury. No. 1173. A. M. M. collection. 

4. Perforation of Articular Ends Across the Joint. — These are the 
most favorable of the joint perforations to treat and this is especially 
so with the shots delivered perpendicular to the joint surface, in which 
case the joint is traversed by the shortest route, inflicting a minimum 
amount of injury. (Figures 130 and 131.) Long oblique tracks through 
the bones are attended with more traumatism and greater liability to 
infection as in the case of the long narrow grooves seen in shots which 
gutter the joint ends. The tendency to the development of infection 
in all joint wounds is measured by the size of the wounds of entrance 
and exit in the skin and the degree of traumatism in the structures 
entering into the formation of the joint. It is obvious from this 
statement that the amount of infection is largely dependent upon the 
sectional area of the bullet. Perforations of the articular ends of 



324 



GUNSHOT WOUNDS 



bone by the armored bullets are generally clean cut without Assuring 
or splintering. In cases where the track of the bullet is near the sur- 
face of the bone, Assuring into the joint may occur, but these cases 
simulate those described under the Lesions of Joints Marked by Groov- 
ing, etc., and they are correspondingly serious. 




Fig. 130. — Radiographs of left knee, showing lateral and postero-anterior view of left knee 
in the case of Pvt. Ernest Knowles, Co. "D," 21st U. S. Inf., wounded in Philippine Insurrection 
Oct. 28, 1899, by a ricochet .45 cal. brass-jacketed Remington bullet. The ball entered external 
surface of thigh about its middle and passing perpendicularly through osseous structures of knee- 
joint, it lodged in the head of tibia from which it was removed by the author in May, 1900. A shot 
obliquely or transversely disposed through the joint by such a large missile would have caused much 
destruction of bone with a less happy result. Remote effects: Some stiffness and pain in knee which 
disappeared partially after the bullet was removed. The photograph of bullet appears in Fig. 131. 
U. S. Soldiers Home X-ray Laboratory. Dr. A. B. Herrick, X-rayist. 



(5) Comminution of the Articular Ends of Bones. — Extensive trau- 
matism of joint structures is usually caused by gunshot from shell 
fragments, large lead bullets, shrapnel balls and proximal shots at 
contact or only a few feet from the muzzle by the high-power military 
rifles of the present. (Fig. 132.) From the amount of fragmentation 
of the osseous structures, laceration of the soft parts and the larger 
skin wounds, these wounds are the most dangerous variety of joint 
injury, because of the presence and spread of infection which is almost 
inevitable in war wounds, especially in active campaign. 



GUNSHOT WOUNDS OF JOINTS 



325 



Symptoms of Wounds of Joints. — The first and almost invariable 
result of gunshot of a joint is the appearance of effusion composed of 
synovial fluid and blood which increases for the first twenty-four 
hours. In the less severe cases, under quiet and fixation of the limb, 
absorption will take place in 
from two to four weeks. A 
general rise of temperature will 
usually appear during this time 
from absorption of fibrin ferment 
in the effused blood or, as has re- 
cently been suggested, from the 
presence of staphylococcus 
albus. This rise in tempera- 
ture is transient and slight and 





Fig. 131. Fig. 132. 

Fig. 132. — Shows the result of an experimental shot in the cadaver of a man of 60 years by the 
U. S. A. pointed rifle bullet of .30 cal. impressed by its maximum velocity of 2700 f.s. Aside from 
the shattering effects of high velocity the brittle condition of the bones of the aged no doubt con- 
tributed to the degree of traumatism. Army Medical School X-ray Laboratory. 



very unlike the fever and constitutional disturbance which accom- 
panies acute septic arthritis. 

Escape of synovial fluid from the external wound occasionally 
occurs, and when it does it is positive evidence that the synovial 
sac has been penetrated, but cases of this kind are confined to large 
external wounds having free communication with the joint. When 
synovia is not seen, the diagnosis of joint injury is to be made from 
the track of the bullet as determined by the location of the external 



326 GUNSHOT WOUNDS 

wounds. When doubt of joint implication exists, the surgeon should 
nevertheless treat the case as one of joint injury. 

Joints are sometimes implicated in injuries to the shafts of the long 
bones by the high-power rifles. Fissures of great length are frequently 
seen in the femur and humerus more often from shot injuries at the 
mid ranges. The fissures may or may not be subperiosteal and they 
extend into the neighboring joints causing more or less effusion into 
the synovial sac. These cases are difficult to separate from the vibra- 
tion synovitis of Mr. Makins. In cases where the wound becomes 
septic, however, the presence of fissures into the joint becomes un- 
mistakable because the septic process invariably extends along the fis- 
sures into the joint. 

Treatment. — This includes (1) amputation, (2) excision and (3) 
conservative treatment. 

(1) Amputation was the rule of treament in all wounds of large 
joints with the possible exception of the elbow in the days of the old 
armament. The lesion was then more extensive and sepsis was 
present in all cases. The surgeon's ability to control sepsis and the 
favorable character of the lesions inflicted by the modern military 
rifle have reduced amputation for joint wounds to a minimum in 
the wars of the present. Primary amputation is only done now in 
cases of great destruction of the soft parts and interference with the 
blood and nerve supply, such as are common from shell wounds. The 
surgeon is often tempted to save limbs when the vessels and nerves 
alone have been destroyed and when the injury to the joint proper 
is of secondary importance. Our experience among invalided and 
discharged soldiers at the U. S. Soldiers Home, Washington, has con- 
vinced us that conservatism can be carried too far and that when 
the blood and nerve supply have suffered extensive destruction ampu- 
tation is better than conservation in the long run. The atrophied 
and paralyzed members have to be sacrificed ultimately. Primary 
amputation avoids a great deal of protracted suffering, and further- 
more the soldier's pension, which is liberal for the loss of an arm or 
leg in our country, becomes at once available. 

As far as known no amputation resulted either in the Spanish- 
American or Boer War for gunshot of a large joint by the small jacketed 
bullet. An amount of destructive effect necessary to require amputa- 
tion from such a source could only arise at the proximal ranges when 
the bullet makes au irregular impact. Near shots are uncommon 
among war wounds now, they are more often the result of accident. 



GUNSHOT WOUNDS OF JOINTS 327 

(2) Primary Excision. — For the same reasons that primary amputa- 
tion has wellnigh disappeared from the field of military surgery, 
primary excision for gunshot of the larger joints is correspondingly 
rare. Except the removal of pieces of comminuted bone from 
wounds caused by shell fragments or shrapnel balls, nothing in the 
nature of an excision is done. 

The knee and elbow may and do sometimes require secondary 
excision, at a remote period, to correct faulty positions or ankylosis, 
but beyond this, formal excisions for the ulterior effects of gunshot are 
seldom done in war hospitals. 

(3) Conservative Treatment. — Before the days of antiseptic treat- 
ment and the use of the new armament the recognized mode of treat- 
ment of joint wounds was by primary amputation. Of the two fac- 
tors that have brought about the present change in the treatment 
of joint wounds, it is difficult to state which of the two should receive 
the most credit. Joint wounds by the reduced-caliber bullets are 
generally so trivial, as far as the injury to cancellous tissue is con- 
cerned, that beyond a clean-cut perforation that heals in a few weeks 
under proper immobilization, the lesion has no characteristic feature 
worthy of mention. The external wounds generally heal under a 
scab and although a clean dressing is applied to the surface, it is 
doubtful if it plays much of a part in securing the primary healing that 
takes place in nearly all cases. At the same time that we would under 
no circumstances minimize the use of a clean dressing, we are very 
much of the opinion that the happy outcome of joint wounds under 
present conditions comes more from the humane nature of the lesion, 
and immobilization, than from anything else. 

In joint injuries by the large-caliber bullets, and other missiles, 
which inflict more or less comminution, the antiseptic details necessary, 
no doubt, play a great role in saving limbs, and for these cases we 
would ascribe the greatest amount of credit to antiseptics. 

The Spanish-American and Boer Wars, in a practical maimer, 
plainly demonstrated the humane nature of joint wounds by the new 
military rifle, but we are happy to state that among the experimenters, 1 
we were among those who foretold the outcome of joint wounds exactly 
as we find it to-day. 

In cases of simple wounds of the synovial membrane and clean 
perforations of the epiphyseal ends of bones the conservative manage- 
ment of a joint wound comprises the use of a clean dressing applied 

1 Report Surgeon General, U. S. Army, 1893. 



328 GUNSHOT WOUNDS 

to as clean a field as one can obtain. Next the parts should be 
immobilized in a position to secure a useful limb should anchylosis occur. 
Passive movements and gentle massage should be practised as soon 
as the external wounds have entirely healed. Probing or any kind 
of exploration is not permissible. 

In joint injuries exhibiting comminution of a moderate or severe 
kind, with lesion short of the destruction of soft parts, demanding 
primary amputation, experience has shown that the conservative 
method is still worth while. Such cases are only likely to arise from 
shell fragments, shrapnel balls, and proximal shots by the new 
military rifle. Except in cases in which the soft parts are badly 
damaged with interference of the blood and nerve supply, conserva- 
tion, even though fragmentation is well pronounced, will yield useful 
limbs, if careful antiseptic treatment is persistently and rigidly carried 
out. These cases, unlike the more simple injuries to joints, require 
exploration, removal of loose fragments, irrigation, drainage, and 
immobilization. 

In the emergent conditions of active campaign the military 
surgeon is often handicapped in carrying out all the painstaking details 
necessary to insure conservation. If he finds that he cannot maintain 
extension and counter-extension, and proper immobilization, because 
of enforced transport over any and all kinds of roads in unstable 
vehicles, he will then have to consider the question of primary amputa- 
tion as a preferable alternative. Conditions of this kind are practi- 
cally unknown to our civil confreres, but they are common enough with 
us, and for that reason military surgeons are often compelled to 
sacrifice limbs — lower limbs especially — that could be easily saved 
in fixed hospitals. An amputated limb will stand transport better 
than a comminuted joint, and the danger to life is far less by practising 
primary amputation. 

From the present European War we find no special advance in the 
treatment of the war injuries of joints. 

Col. H. M. W. Gray 1 to whose writings we will again refer when 
dealing with septic wounds of the knee joint, recommends the same 
radical treatment already referred to in all joint cases. At the onset 
he practises excision of the skin and superficial soiled or necrotic muscle 
and fascia. The wound should be enlarged promptly and freely 
when deemed necessary; all foreign bodies should be removed as soon 
as localized by X-ray evidence; the synovial cavity should be flushed 

1 Op cit. 



GUNSHOT WOUNDS OF JOINTS 329 

with a 5 per cent, saline solution removing all blood clot. In very 
acute cases, fresh incisions should be made; the edges of the mucous 
membrane should be sutured if sepsis is not acute; insert drainage tube 
down to and not into the synovial membrane and fill the rest of the 
wound with a salt tablet and gauze dressing. When fluid in the joint is 
removed by puncture inject formalin-glycerin or ether, etc., through 
fresh puncture. Employ superficial dressings; immobilize in suitable 
splint. When these measures fail free arthrotomy, or possibly ampu- 
tation, is in order. 

If suppuration should take place in a joint while the surgeon is 
practising the conservative method, he should make free incisions in 
the dependent parts with liberal drainage and free irrigation with 
antiseptic solutions of suitable strength twice per day. 

Gunshot Wounds in the Shoulder. — The wounds of this joint are 
necessarily often accompanied by wounds of adjacent parts like the 
clavicle, scapula, thorax, neck, face, forearm and hand. The projectile 
may enter the joint from the immediate front or from a lateral direc- 
tion. Wounds of the shoulder are often received in this way but do 
not often implicate the joint proper and we may add further that gun- 
shot wounds involving the joint have diminished in frequency with 
the introduction of the small-caliber military rifle. The reason for 
this is obvious. The largest calibers of the old armament were 
themselves almost as large as the globular head of the humerus, so 
that a hit in the vicinity of the joint was correspondingly more apt 
to open its capsule or cause lesion of its bony structure. 

The statistics of former wars showed that gunshot of the shoulder- 
joint constitutes 2 per cent, of all wounds and 16 per cent, of all joint 
wounds. From our Civil War Otis reports 1400 cases of gunshot 
wounds of the shoulder-joint. ■ In seventy-two of these there was no 
injury to bone. They were treated expectantly with a mortality of 
8 per cent. In 1328 the articular extremity of the humerus or 
scapula was primarily involved. In 50 per cent, of the cases excision 
of the head of the humerus was practised; the expectant plan of 
treatment was followed in 37.50 per cent, and amputation was 
done in 12.50 per cent. The general mortality was nearly 33 
per cent. 

In 4919 gunshot wounds recorded in the Annual Report of the 
Surgeon General for 1900 occurring in the Spanish-American War and 
Philippine Insurrection there were nine gunshots of the shoulder-joint 
with one death, the immediate cause of which is not stated. Four 



330 GUNSHOT WOUNDS 

of the cases were restored to duty, one was discharged at expiration 
of term, and the other three were discharged and pensioned. The 
wounds were the result of rifle bullets as follows : 4 Mauser, 3 Reming- 
ton, 1 Krag-Jorgensen and 1 bullet not specified. 

The amount of destruction that occurs in fracture of the bones 
entering into the formation of the shoulder-joint depends primarily 
on the sectional area of the bullet at the time of impact and next upon 
its remaining velocity. 

The jacketed, present-day rifle bullet perforates or grooves the 
cancellous tissue of the anatomical neck, the lesion depending upon 
the angle of impact with the globular head. In either case there is 
little or no tendency to fissures. Formerly larger-caliber lead bullets 
caused great comminution of the globular head of the humerus. Even 
in shots which struck the anatomical neck at a tangent, there was not 
the tendency to gutter that there is with armored bullets. 

A projectile striking the humerus at the junction of the anatomical 
and surgical necks will cause comminution of the globular head or 
separate it from the shaft. The separation will take place in the 
epiphyseal junction, thereby cutting off its blood supply, and incur 
liability to necrosis. Delorme was among the first to point out this 
particular lesion. 

When the projectile hits the surgical neck, fissures will extend 
above to the globular head and below into the shaft and the comminu- 
tion will be more extensive because the resistance of the compact bone 
in the surgical neck is greater. In such cases the upper fragment 
remains adherent to the periosteum and soft parts and, furthermore, it 
retains its blood supply, a condition which insures ultimate union of 
the fragments. 

Some writers, Chenu among them, have reported the rare occur- 
rence of dislocation of the head of the humerus as a complication of 
gunshot of the shoulder-joint. 

Injury to the head and neck of the scapula are rare and when hit 
by armored bullets they are generally grooved or perforated. Lead 
balls and shrapnel may cause extensive comminution. 

Treatment. — In cases of simple capsular wounds and perforations 
of the anatomical neck or head of the scapula the wounds and sur- 
rounding surface should be asepticized with antiseptic solutions or tinc- 
ture of iodine. An antiseptic pad should be placed in the axilla and 
side of the chest. The arm, fore-arm and hand should be secured to 
the side and front of the chest by a wide roller bandage. No undue 



GUNSHOT WOUNDS OF JOINTS 331 

amount of examination to ascertain the extent of injury should be 
made. This can be later ascertained by X-ray examinations. Ex- 
ploration by finger or instruments is not permissible. 

When fracture by larger bullets or shell fragments occurs with 
comminution the management of the case has to be considered 
under the plans of (a) Conservative treatment, (b) Excision or (c) 
Amputation. 




Fig. 133. — Skiagram showing the result of gun-shot by the .30 cal. Krag-Jorgensen bullet in a 
U. S. soldier who was shot at a distance of 5 feet, in Oct., 1901. He was treated in accordance with 
modern methods by removing all detached fragments, etc. There is excellent use of the arm. 
Exposure was made in 1911. Letterman General Hospital Laboratory. 

(a) Conservative Treatment. — This method should be practised 
in any kind of injury with comminution, short of destruction of the 
great vessels and nerves supplying the upper extremity. Later, if 
conservation fails, secondary excision or amputation can be performed 
with very little if any additional risk to life. If deemed advisable a 
thorough examination under a general anesthetic may be made to 
ascertain the amount of injury and for the removal of loose fragments. 



332 



GUNSHOT WOUNDS 



In this examination the wounds may be enlarged to facilitate the ex- 
ploration and subsequent drainage. No fragment should be removed 
unless it is found to be entirely isolated. 

Irrigation with boric-acid solution or a 1-4000 solution of bichloride 
of mercury should next be made, drainage provided for, and after 
applying a clean dressing the limb should be immobilized. 

From 50 to 60 per cent, of gunshots of the shoulder treated by the 

conservative method recover with 
partial or complete anchylosis and 
for this reason massage and pas- 
sive motion should be practised 
early — as soon as the external 
wounds have healed. (Fig. 133.) 
(b) Excision. — Before the days 
of antisepsis and the change in the 
armament primary excision was 
the favorite method of treatment 
in nearly all wounds of the 
shoulder- joint implicating its bony 
structures. Surgeons found by 
wide experience that their formal 
excisions, which were done with a 
view to removal of all fragments 
and most of the lacerated tissues, 
left a comparatively clean opera- 
tive wound which was not so prone 
to the development and spread of 
infection as the original wound 
caused by the crashing effects of 
the projectiles of that day. For 
this reason excisions were more 
popular than attempts at conservation. (Figure 134.) 

Now that we ward off sepsis by antiseptic methods, and that the 
character of the wounds has become less grave, formal primary ex- 
cisions are not required. No operative interference is done except 
occasionally to remove loose fragments of bone, missiles and lodged 
pieces of clothing. 

When suppuration sets in with sepsis as a result of necrosis in and 
about the joint in cases where attempts at conversation have failed, 
secondary excision is in order. The excision should be thorough, and 




Fig. 134. — A recent radiogram showing ex- 
cision in the case of Benj. R. Pratt, an ex- 
volunteer soldier who was shot in the shoulder 
in the Civil War in 1863. Character of mis- 
sile unknown. Army Medical School collec- 
tion. 



GUNSHOT WOUNDS OF JOINTS 333 

effective drainage with persistent irrigation should be employed. By 
adopting this plan of treatment the arm will be saved and amputa- 
tion avoided. 

Amputation. — As stated already primary amputation is indicated 
for severe comminution of the bones entering into the formation of 
the joint, with extensive laceration of the soft parts, and injury to 
the large vessels and nerves. Secondary amputation sometimes be- 
comes necessary in attempts at conservation when osteomyelitis, 
gangrene or secondary hemorrhage appear as complications. Necrosis 
of a large portion of the humerus was a cause for amputation at the 
shoulder in preantiseptic days and the same may be said of long- 
continued suppuration in the joint. The greater number of the 
causes mentioned will seldom be met with when our modern methods 
of treatment have been followed. 

Gunshot Wounds of the Elbow. — The wounds of this joint average 
from 1.5 to 2 per cent, of all wounds in war, and 35 per cent, of all 
joint wounds. The frequency of gunshot of the elbow ranks next to 
that of the knee. 

The amount of lesion, as well known, is proportional to the sectional 
area of the projectile on impact. With the use of the older military 
rifle as well as shots from shrapnel and pieces of shells, there is much 
damage to osseous structures entering into the formation of the joint. 
Smaller projectiles, and especially the jacketed present-day bullets, 
inflict injuries that are more often circumscribed and restricted. 
Antero-posterior shots groove the prominence of the condyles of the 
humerus or perforate the epitrochlear notch with little Assuring. 
Contact shots — shots in which the impact of the bullet is conveyed to 
the articular end of the humerus without causing more than slight 
grazing — sometimes show separation of the epiphysis from the shaft, 
as in simple fracture. Shots disposed transversely through the 
epiphyseal junction badly comminute the lower fragment into the 
joint. 

Injuries to the head of the radius consist of grooves and perfora- 
tions, and when the ball strikes toward the shaft, away from the 
epiphyseal junction, a fracture with fissures occurs, such as one is apt 
to find in injuries to diaphyses generally. 

Shots through the joint which involve the ulna rarely cause 
complete separation of the fragments. They partake more of the 
nature of grooves and perforations. Transverse shots at the base of 
the olecranon are apt to show long fissures into the shaft, while antero- 



334 GUNSHOT WOUNDS 

posterior shots through the olecranon proper exhibit perforation with 
radiating fissures above and below, with fragments held together. 

Taken as a whole gunshot lesions of the elbow- joint lend themselves 
especially to the conservative method of treatment. 

Conservation. — This method of treatment, like all the operative 
measures had its share of mortality in preantiseptic times. Otis 
records a mortality of 10.3 per cent, in our Civil War. This was 
slightly lowered in the Franco-German War of 1870-71, viz., 9.8 per 
cent. 

With the advent of antisepsis, conservation has become the method 
of choice in all injuries of the elbow, save the few which from the 
extreme amount of traumatism to bone and soft parts demand primary 
excision or primary amputation. Conservation is to be practised in 
all synovial wounds and all bone injuries, like those to the articular 
ends of the humerus, ulna and radius already mentioned. As long as 
the nerve and blood supply are not entirely destroyed, no matter what 
the bone lesion may be, there is hope of a useful hand, which is after 
all the great desideratum, and conservation should be tried. Con- 
servation is only contraindicated by traumatism of the joint com- 
plicated by injury to the brachial artery; and yet in preantiseptic 
times some of the leading surgeons, notwithstanding the gravity of 
such extensive traumatism, essayed conservation, and sometimes suc- 
ceeded. In these daring attempts they pinned their faith on the 
abundant opportunity for collateral circulation that is normally 
present about the elbow. 

When we remember that the rules of conservation as they are 
now taught were established in preantiseptic times, we are all the more 
hopeful of its value under our present methods of wound treatment. 
One should, however, remember that conservation in the extreme 
traumatisms referred to — those implicating the blood supply — find no 
application in active campaign when transport is impending. Con- 
servation with a precarious blood supply is apt to be attended by 
gangrene, an eventuality that requires watchful care, and an amount 
of attention that can seldom be bestowed, except in fixed hospitals. 
In such cases the military surgeon is often compelled to advise ampu- 
tation when his civil confrere is able to save a limb. 

Although the aim of the surgeon at conservation is directed toward 
a movable joint, the experience of war surgery affords but little en- 
couragement for such an outcome. Otis records but three cases with 
good motion in our Civil War, the majority recovered with true bony 



GUNSHOT WOUNDS OF JOINTS 335 

anchylosis. Audet 1 found in 1135 cases of gunshot of the elbow from 
various sources but 2.5 per cent, with good motion. Following the 
Franco-German War of 1870-71 out of 163 cases Dominick found 
complete anchylosis in 82.8 per cent., partial anchylosis in .11 per 
cent, and good motion in 6.2 per cent. 

We will expect better results in cases where suppuration is avoided 
hereafter. This will be especially so in those cases of injury to the 
synovial membrane alone, and the lesser bone injuries. The function 
of pronation and supination will be retained in cases where the head 
of the radius and its articulating surface escape injury notwithstanding 
the occurrence of anchylosis in other parts of the joint. 

In the recent wars of which we have record nearly all cases were 
treated by conservation. Out of forty-four cases of gunshot of the 
elbow-joint in the Spanish-American War the mortality was 2.2 per 
cent, and in the Boer War out of forty-nine reported cases there was 
one death following amputation. 

In practising conservation of elbow cases the limb should be 
fixed in a position that will give the greatest use of the hand should 
anchylosis result. To this end the forearm is flexed on the arm at 
a trifle less than a right angle and the hand should occupy a position 
half way between pronation and supination, the thumb pointing 
upward. The fixation apparatus should be so placed as to permit 
redressing of the wound without disturbing in any way the attempt 
at immobilization. 

Exploration of the wound is only necessary in cases showing com- 
minution of the articular ends of bones. In such cases the external 
wounds should be enlarged if necessary, or the joint may be exposed 
by a posterior and external incision running in the axis of the limb. 
All splinters and fragments of bone, pieces of clothing and missiles 
should be removed. The joint and wound should be irrigated thor- 
oughly with a weak bichloride solution 1 to 4000. Drainage should 
be maintained for a few days. 

The occurrence of infection should be met by thorough drainage 
and frequent irrigation, and if it persists secondary excision will have 
to be considered. 

In less serious cases, where there is reason to suspect slight bony 
lesion, no exploration of any kind should be undertaken. Such 
cases require a clean dressing applied to a clean field, and fixation. 
In cases which progress to a successful termination without evidence 

1 Audet, Manuel de chirurgie d' armee, Paris, 1886. 



336 GUNSHOT WOUNDS 

of inflammation early passive motion should be practised. The time 
to commence passive motion will vary, but it should not be carried 
on to any extent before the healing of the external wounds. 

Excision of the Elbow. — No primary excision of the elbow was 
done during either the Spanish-American or Boer War and such an 
operation will seldom be required in the war surgery of the future. 

The operation is indicated in those cases that show comminution 
on exploration, with fragments entirely detached. If operation be- 
comes imperative, the weight of opinion at present favors a radical 
rather than a modified excision. The mere removal of fragments is 
usually followed by anchylosis and the end results are not good. 
Provided the injuries to soft parts and nerves are not as extensive 
as to incur flail joint or useless hand, a complete excision is 
preferable. 

Complete bony anchylosis of the elbow is very trying. It often 
leads to the necessity for excision at a remote period, the results of 
which are generally satisfactory. Complete primary excision is there- 
fore the operation of choice whenever the lesion requires excision at 
all. In support of this view, the experience of the older surgeons 
serves us in good stead. We know the value of primary excisions of 
the elbow, as far as the use of the arm and hand are concerned, by their 
statistics which are abundant. According to Gurlt the statistics of 
primary excision after the Franco-German War of 1870-71 were 
"good" in 29 per cent, of the cases, "moderate" in 53 per cent., and 
"bad" in 17 per cent. Otis reporting upon complete excision in 
our Civil War states that " a fair proportion retained a fair amount 
of control over the uses of the forearm and hand, a smaller number 
had very serviceable limbs, and in a few instances the usefulness of the 
limbs was hardly at all impaired." The Civil War surgeons were 
deterred from doing complete excision because of the mortality which 
attended operative procedures in that day. In the class of cases de- 
manding excision, we should expect no mortality of any consequence 
in the future and the functions of the limb will no doubt be better pre- 
served than they have been hitherto. 

Complete primary excision is not to be recommended in gunshot 
of other joints, but for the reasons mentioned we believe that excisions 
of the elbow in the class of badly comminuted fractures mentioned 
will find favor in the wars of the future. 

Secondary Excision. — This procedure will seldom be required 
when the wound treatment has been properly carried out. In pre- 



GUNSHOT WOUNDS OF JOINTS 337 

antiseptic times it was necessarily frequently done as a measure to 
save life when active inflammation had set in after attempts at con- 
servation. Persistent chronic arthritis and necrosis were also among 
the later causes of secondary excision, and then excision was practised 
at a remote period. When the muscles remain in good functional 
condition excellent results are obtained from excisions at a remote 
period. Stevenson's experiences in such cases were exceptionally good 
after the Tirah Expedition and Boer War. He states that " all of the 
cases operated on were improved and in some of them flexion and ex- 
tension were as complete as could be desired while the limb and new 
joint were strong and useful." If the case requires removal of the 
articular ends, the less bone taken away the better. The cases require 
persistent and continued attempts at passive motion, massage and 
electricity. 

Primary amputation of the elbow is done as in other joint injuries 
when extensive injury to bone and soft parts is present with involve- 
ment of nerve trunks. Injuries to the brachial and its branches which 
threaten the occurrence of gangrene are debatable causes for amputation. 
The rich collateral circulation about the elbow often makes it worth 
while to attempt the saving of a limb if the remaining lesions are of a 
character to warrant the effort. 

Secondary Amputation. — The old-time common sequelae and 
complications of gunshot wounds like osteomyelitis, necrosis and 
secondary hemorrhage, were rather frequent causes for amputation in 
gunshot of the elbow. The more common causes of secondary am- 
putation now are for limbs which have become useless appendages as a 
result of the successful practice at antisepsis. 

Gunshot Wounds of the Wrist and Carpus. — Gunshot of the wrist 
was not specially fatal in former wars. Otis makes out a mortality 
of 12.9 per cent, out of 1496 shot fractures of the bones of the wrist 
after all plans of treatment, like conservation, the various excisions, 
and amputations incident to severe lesions or complications like 
inflammation, sepsis, etc. 

The lesions of the joint from gunshot will depend upon the size of 

the projectile. Frightful lacerations will occur from shell fragments, 

and shrapnel balls hitting the joint in a transverse or oblique direction. 

Lead balls from pistols or rifles shatter the lower end of the radius or 

ulna into the joint causing fissures to extend into the diaphysis. The 

first or second rows of carpal bones may be injured by dorso-palmar, 

oblique or transverse shots. Injury to the lower end of the radius and 
22 



338 GUNSHOT WOUNDS 

ulna implicating the joint is the most frequent lesion found, and the 
dorso-palmar direction is less harmful to the anatomical structures 
than the transverse or oblique perforations. 

The effects of the modern bullet of small caliber are less likely to 
comminute the joint ends of the ulna and radius or the carpal bones. 
They groove and perforate the former and only shatter the carpal bones 
which they strike. They do not divide tendons nor lacerate tissues as 
the old lead bullets did, hence the danger of sepsis is naturally not so 
great. No deaths are reported from the Spanish-American or Boer 
War. 

Conservative Treatment. — This method of dealing with gunshot 
fractures of the wrist has been practised since the days of Pare and 
it is more applicable to-day than ever before. From our Civil War, 
and the Franco-German War of 1870-71, Otis and Scheven report a 
mortality after the conservative plan of treatment of 7.6 per cent, and 
11.4 per cent., respectively. 

The results of conservation to the function of the hand and fingers 
are very much influenced by the presence of inflammation in the wound. 
In the preantiseptic era when infection of all wounds was the rule, 
the patients recovered with anchylosis in the large majority of cases. 
But few soldiers recovered with function of the hand and fingers 
sufficiently preserved to enable them to return to the ranks. Out 
of 307 cases in the Franco-German War Scheven found 264 or 82.4 per 
cent, who recovered with complete anchylosis, and hands more or less 
useless, and 56 or 14.6 per cent, with incomplete anchylosis and slight 
use of the hand. In the same war Gurlt out of sixteen wounded 
treated conservatively, found but one retaining the function of the 
hand sufficiently to permit him to be restored to duty. In our Civil 
War out of fifty-eight gunshots of the wrist, fifty-one recovered with 
anchylosis of the wrist, five with mobility marked by deformity, and 
three with flail joint. These disabilities were almost entirely the result 
of adhesions in the joints and tendon sheaths as a result of inflam- 
matory exudate. 

Under our present plan of wound treatment, which is directed 
toward the prevention of sepsis, in gunshot of the wrist of the less 
severe type, there should be no serious loss of function in the hand. 
The experience in the Spanish-American and Boer Wars fully justifies 
this statement, and the same will no doubt apply to the results in the 
Manchurian campaign when the official reports become accessible. 

In the minor degrees of injury the wounds should be enlarged if 



GUNSHOT WOUNDS OF JOINTS 339 

necessary and loose fragments of bone removed. Irrigation of the 
wound and synovial sac should next be thoroughly done, drainage 
provided for, and the limb immobilized, in a clean dressing, with the 
elbow slightly flexed. 

The appearance of suppuration in the joint at any time during 
the treatment should be met by free incisions on the sides of the wrist, 
to forestall abscess formations up the arm. When the joint has been 
cut into, additional exploration should be made for loose fragments 
of bone and if necessary a partial secondary excision may be made. 
Unfortunately the results, when extensive inflammation occurs and 
partial secondary excision is required, are not very encouraging as to 
the ultimate function of the wrist and fingers. Such cases only too 
often end in grip-hand which is not much better than no hand at all. 

Primary Excision of the Wrist. — Complete and partial excision of 
the wrist for gunshot gave discouraging results in preantiseptic times. 
Otis relates six cases of complete primary excisions, one ending fatally 
after amputation. The other five recovered with impaired function 
of the hand, "but all things taken into consideration, in a better con- 
dition than if they had been subjected to amputation.' ' If those 
were the results, and the impression of the utility of the hand after 
complete excision in preantiseptic times, the outcome that must ob- 
tain henceforth should be more encouraging still. Complete primary 
excision is only required for wounds caused by shell fragments or lead 
balls which cause much disorganization of the bony articulation. 
Smaller projectiles and shots from reduced-caliber rifle bullets in any 
but proximal ranges will cause less fragmentation, and as this class of 
wrist wounds will form the larger number, partial primary excisions 
will be required in the great majority of cases. 

In our CivilWar partial primary excision and secondary excisions 
gave twice the mortality observed after the conservative plan of treat- 
ment. Sepsis played a great role in this outcome. The same may 
be said of the results concerning the utility of the hand. In the 
Franco-German War Gurlt found the end results in partial excision 
"good" in 6.25 per cent, of the cases, and "moderate," "bad" and 
"very bad" in 93.75 per cent. 

Shots from the modern rifle bullet will not as a rule cause much 
impairment of the wrist-joint. The bone lesion will be marked by 
perforation or slight guttering of the articular ends of the ulna and 
radius, which will heal aseptically in the large majority of the cases. 
Mr. Makins "never saw any trouble result from perforations of the 



340 GUNSHOT WOUNDS 

carpus" in the Anglo-Boer War. Secondary excision becomes neces- 
sary when sepsis as a complication makes its appearance in joints 
undergoing conservative treatment. The surgeon will have to decide 
whether partial or complete excision is to be employed. 

In the after-treatment, fixation should be maintained in such a 
way as to permit passive motion of the thumb and fingers. Wadding 
should be placed between the thumb and index finger to prevent the 
former from becoming more or less anchylosed next to the latter. 
Passive motion of the digits should be commenced in a day or two 
and maintained along with massage and faradization all through 
convalescence and longer. The utility of the hand depends almost 
entirely on the attention thus bestowed. 

Primary amputation is only required after extensive lesion to the 
soft parts and bony articulation from shell fragments, larger rifle 
projectiles, and wounds by fine and coarser pellets out of shot guns. 

Gunshot Wounds of the Hip-joint. — The frequency of gunshot of 
the hip-joint as determined by Fischer was thirty cases for every 1000 
wounds of all anatomical parts, and 5 per cent, of all joint wounds. 

Of the injuries to the large joints those of the hip were the most 
fatal. The diagnosis was always uncertain, and oftentimes obscure, 
and in active campaign they were among the most difficult to treat. 
Otis gives the results in 386 cases treated in the Civil War from the 
Union and Confederate armies. Of this number, in 40, the part of 
the joint involved is not stated. The acetabulum alone, or the aceta- 
bulum and some part of the head, neck, or shaft of the femur figured in 
the lesion in seventy-four cases. Sixty-four were treated by conser- 
vation and but two recovered, the fatality being 96 per cent. Nine 
were treated by excision, one by amputation, with a mortality of 100 
per cent. The head of the femur alone, or the head and neck, the head, 
neck and trochanters, the head, neck and shaft, the upper portion 
of the femur or trochanter involving the joint were included in the 
lesion in 272 cases. Two hundred and three of these were treated by 
conservation with 160 deaths or a fatality of 58 per cent, as compared 
to 96 per cent, for the group which includes lesion of the acetabulum 
also. Out of forty-five excisions in the last group forty-three died, the 
mortality being 95 per cent. Of nineteen cases subjected to ampu- 
tation, with a question as to the result in two, death occurred in 
every case. 

By dividing the cases in the two groups — one where the acetabulum 
is implicated in the lesion, and the other where it is not, we find that 



GUNSHOT WOUNDS OF JOINTS 341 

treatment by excision and amputation was alike fatal in both, and that 
treatment by conservation of the cases with acetabular involvement 
gave an excessive mortality as compared to what we find in articular 
lesion without acetabular involvement, viz., a mortality of 96 per 
cent, as compared to 58 per cent. 

Although sepsis might account for a large percentage of the 
fatalities in each group, it cannot account for the great divergence in 
the mortality of the two groups, for we must admit that sepsis arising 
from lesions without acetabular involvement should be as fatal as that 
arising with acetabular involvement. The larger death rate among 
the acetabular cases was no doubt connected with adjoining pelvic 
complications incident to the crashing effects of the large rifle pro^ 
jectiles of that period, and in this sense the death rate of this group 
cannot be taken as figuring entirely in the death rate of hip cases 
alone. 

The comparatively low death rate of 58 per cent, in the second 
group, viz., in those cases showing lesion of the head, neck, alone or 
combined, or shaft, trochanter, and neck combined was not a bad 
result for that time and mode of treatment. If such cases had been 
treated antiseptically, after our present methods, without exploration 
with probes or fingers, except when urgently required, we have 
reason to believe that the results would have been exceptionally good, 
notwithstanding the comminution attending injuries by the old-time 
projectiles. 

Because of the present-day tactics of firing in the prone position, 
the hip-joint is not so frequently wounded as formerly. When the 
soldier is lying down under cover the hip is one of the least exposed 
parts of the body. Mr. Makins saw but one case — a grazing of the 
edge of the acetabulum — in the Anglo-Boer War. Stevenson 
reports seven cases in the same war, and the Surgeon-General, U. S. 
Army, 1 reports three cases as having occurred in the Spanish- American 
War. 

Pathology.— The effects of projectiles on the hip-joint include 
lesion of the (1) capsule, (2) trochanters, (3) the head of the femur, 
(4) the neck, and (5) the portion of the surgical neck adjacent to the 
intertrochanteric line. 

(1) Lesion in the Capsule. — Projectiles passing antero-posteriorly 
or in the reverse direction can injure the capsule by grazing or actually 
perforating its cavity opposite the head and neck without implicating 

1 Reports of the Surgeon General, U. S. A., 1899-1901. 



342 GUNSHOT WOUNDS 

the bony structures. In the same way the capsule may be contused and 
even perforated by shots disposed transversely from without inward 
or vice versa in front or behind the joint without implicating the osseous 
structure of the articulation proper. Otis refers to forty-nine cases of 
perforation of the capsule in the Civil War. Shots from the modern 
military rifle are especially apt to perforate the capsule without 
implicating the bony parts of the joint. Injury to the capsule by the 
modern rifle bullets with and without bone lesion is more often linear 
in shape, with apparently little or no loss of substance. 

(2) Lesions of the Trochanters. — The greater and lesser trochanters 
may suffer contusion, grooving and complete perforation by pro- 
jectiles traveling in any direction, with no special tendency to fissures 
from the point of impact. The lesion is limited for the projectiles of 
hand weapons, but especially so for jacketed reduced-caliber bullets 
in the mid ranges. The perforation by the latter on entering is clean- 
cut, while the lesion at the point of exit is larger and marked by the 
presence of small detached fragments, with others still attached. 
Fissures, if any, are more often subperiosteal and seldom extend 
beyond the limits of the apophyseal structure. Lesion from the 
larger-caliber lead projectiles like those of our .45-caliber Springfield 
rifle were attended with much comminution and fissures extending to 
the shaft and neck. 

(3) Lesions of the head of the femur may consist of contusion, 
slight grazing, grooving, and perforations that are clean or attended 
with more or less fragmentation depending upon the sectional area of 
the bullet. When the force of impact is directed near the epiphyseal 
line with the neck, there is danger of separation of the head from the 
latter as was pointed out in similar shots in the shoulder-joint. The 
lesion is more apt to be circumscribed or to partake of the nature of a 
groove or perforation in shots from armored bullets, at medium ranges. 

(4) Lesion of the Neck of the Femur. — Traumatism may here 
consist of contusion, grazing, grooving or complete perforation with or 
without Assuring. A shot which grooves the circumference of the 
neck is attended with more or less fragmentation, the fragments re- 
maining attached or set free in and about the joint depending upon the 
sectional area, velocity, and density of the projectile. When the 
force of impact causing either a groove or perforation is delivered at 
either end of the neck with Assuring, the latter will be disposed toward 
the epiphyseal line of the end hit, causing complete or partial separation 
of the neck, with the head or the trochanteric region, as the case may 



GUNSHOT WOUNDS OF JOINTS 343 

be. One of the larger rifle projectiles, like that of our .45-caliber 
Springfield rifle, striking the neck in any part of its circumference will 
at times, through the force of the energy delivered, cause fissures to 
occur simultaneously in the direction of the epiphyseal lines at both 
ends of the neck, thus partially or completely separating the latter. 
When the vibratory force is delivered at about the center of the neck 
traversing it through its thickest part the resulting traumatism will 
consist of a clean perforation with more or less Assuring and fragmenta- 
tion- — hits by the modern rifle bullet will be clean-cut like those 
which it exhibits through cancellous tissue generally, while lesion by 
larger-caliber leaden bullets will tend toward fissures and comminution 
which will correspond in extent with the sectional area and velocity of 
the bullet. 

Diagnosis. — Before the introduction of the X-ray the diagnosis of 
gunshot of the hip was difficult and oftentimes impossible. The 
depth of the joint in the tissues made exploration with the finger 
through the wound very difficult. The physical signs of fracture such 
as shortening of the limb, eversion of the foot, disturbed relations of 
the bony points about the joint, or escape of synovia may be absent. 
The articulation is so well supported by muscles, ligaments and fascia 
that severe injury to the joint is possible though the -patient still retains 
power of motion and ability to walk. Now that the armored bullets 
have come into general use this difficulty in diagnosis by the old-time 
physical signs is very much emphasized. The jacketed bullets groove 
or perforate the head, neck and trochanters of the femur almost in- 
variably. Solution of continuity is seldom complete, and the physical 
signs of fracture will be absent as a rule. In such cases one will have 
to rely on the wounds of entry and exit, and take account of the 
tissues that have been traversed by the course of the straight line 
between the external wounds. Again in such cases hereafter the 
surgeon will have to invoke the assistance of X-ray evidence to set 
him aright. Formerly in cases of doubt the surgeon was advised to 
treat all suspicious cases as he would those of actual fracture, and the 
practice is the only safe one to follow now. 

In the absence of the X-ray as an aid to diagnosis, or in cases in 
which the plate may show an obscure finding, there are signs which 
the surgeon should look for. Langenbeck laid stress on swelling of 
the capsule with blood which is most apparent on the front of the 
thigh just below Poupart's ligament. The pressure of the tumor back 
of the large vessels causes the femoral artery to pulsate perceptibly 



344 GUNSHOT WOUNDS 

under the skin of the groin. Again in through-and-through shots 
the exact location of the " dangerous region" in hip cases as laid down 
by Langenbeck must be carefully mapped out. According to him the 
" dangerous region" is included in "a triangle whose base intersects 
the trochanter major, while the femur and the anterior superior spine 
of the ilium form the points of an acute angle." Stevenson suggests 
a dangerous space included in "a triangle the angles of which are at 
the spine of the pubes, the anterior inferior spine of the ilium and the 
outermost point of the great trochanter. The value of any space, 
denned by invariable lines, is necessarily faulty. This was true in the 
days of the old armament, and it becomes more so with the use of 
present-day rifle bullets. The joint capsule may be penetrated by 
reduced-caliber bullets antero-posteriorly or vice versa time and again 
without implicating the osseous structures, by passing above or below 
the neck of the femur. 

Treatment of Gunshot of the Hip. — The management of wounds 
of the hip will be considered under the following heads: (1) Expec- 
tancy, (2) Conservation, (3) Excision, (4) Amputation. 

Expectant Treatment. — This plan contemplates no exploratory or 
operative interference. Immobilization and a clean dressing to a 
clean field are the only requirements of treatment. This plan is ap- 
plicable in doubtful injuries to the joint, in which the external wounds 
and the course of the intervening track are the only evidence which 
tends to lend a suspicion of joint lesion. In such cases, with the use 
of the present armament, there may be wound of the capsule only, or 
slight injury to bone, such as grooving, or a clean-cut perforation. 
In such cases immobilization and a clean dressing have given uni- 
formly good results in the Spanish-American and Boer Wars. 

Conservative Treatment. — This plan of treatment is to be pursued 
after a positive diagnosis of gunshot fracture of the hip-joint has been 
made. The surgical means to be employed are: (1) exploration of 
the joint; (2) removal of bone fragments or missiles; (3) immobilization. 

In cases requiring the measures which aim at conservation there 
will usually be the signs of fracture such as shortening of the limb, 
eversion of the foot, disturbed relations of the bony points about the 
joint, escape of synovia, or lodged ball. In addition there will be evi- 
dence of the character of the lesion from the knowledge of the caliber 
of the projectile which inflicted the injury as judged by the external 
wounds, and also from the velocity of the projectile or distance at which 
the injury was received. Injuries to the bones of the hip-joint by 



GUNSHOT WOUNDS OF JOINTS 345 

shell fragments when not too large; lead bullets of the larger calibers 
from rifles, revolvers and shrapnel; as well as steel-clad bullets from 
pistols and military rifles at proximal ranges, usually cause fragmen- 
tation that requires surgical interference. 

Exploration, when two wounds are present, can usually be practised 
through the wound of exit. This should be enlarged to admit the 
finger when necessary. Missiles or small loose fragments of bone that 
can be readily removed should be extracted with the aid of the finger 
and forceps. Larger fragments that lie absolutely loose, free from bony, 
periosteal or soft parts, will necessitate enlargement of the wound and 
for this purpose the posterior incision employed for excisions should 
be done. The joint and wound should next be irrigated and drainage 
at a dependent point should be provided for. 

Immobilization is the next and last of the measures in the scheme of 
conservation. Fixation of a limb is easy enough in a stationary hospi- 
tal, but in active campaign where the military surgeon encounters 
the majority of his cases, it becomes a vexatious problem — one that 
will often tax the ingenuity of the surgeon to the utmost. During 
enforced transport immobilization is next to impossible. 

The method of fixation must include the whole limb and pelvis, 
and the wounds should remain uncovered by the fixation apparatus, 
with ready access for redressing. 

Plaster of Paris is the most desirable method of fixation as it insures 
immobilization and, when properly applied, extension and counter- 
extension at the same time. Nothing can take its place in any and 
all kinds of transports. Unfortunately, it is not always adapted to 
the emergent conditions of field service on account of the time which 
is required to apply a suitable splint. Surgeons should be thoroughly 
familiar with the method of applying plaster of Paris for use in hip 
cases, because, unless the splint is properly fitted, it does more harm 
than good. 

Fixation of whatever kind aiould be practised at once, from the 
time a man is wounded on the field. In the absence of any better 
method, Delorme and other surgeons advise bandaging the injured 
limb to the sound one after placing sufficient padding between the 
two members in order to avoid discomfort and to secure proper 
position. 

Wire gauze splinting, extension and counter-extension when 
practicable, or any of the methods used in field practice or stationary 



346 



GUNSHOT WOUNDS 



hospitals to immobilize limbs may be employed provided immobiliza- 
tion is complete and well maintained. 

The presence of suppuration in and about the hip-joint should be 
treated by free drainage and frequent irrigation with antiseptic solu- 
tions like mercury bichloride 1-4000. Such cases usually get well 
with more or less anchylosis, but when the suppuration continues 
excision will be in order at a later period, when the active inflammatory 
process has subsided. Ample nourishment and administration of 
stimulants should be given in the meantime, to build up the strength 
of the patient, and to prepare him for such subsequent measures of 
surgical relief as may be deemed necessary. 

As we have already stated in the beginning of this chapter the 
results in future wars will be very encouraging for all the plans of 
treatment and especially for those after conservative treatment. 

Excision of the Hip. — Hitherto the results of this operative 
measure have been alike deplorable in civil practice and active cam- 
paign. We cite below the mortality recorded by Otis for the different 
periods in the clinical history of such cases before the days of 
antisepsis. 



NUMERICAL STATEMENT OF SIXTY-SIX CASES OF EXCISION AT 
THE HIP-JOINT FOR SHOT INJURY DURING OUR CIVIL WAR 



Operations 


Cases 


Per cent. 

of 
mortality 


Recovery 


Fatal 


Total 


Primary operations 

Intermediary operations 

Secondary operations 


1 
2 
3 


32 
20 

8 


33 
22 
11 


96.9 
90.9 

72.7 






Aggregates 


6 


60 


66 


90.9 



Otis again collected the statistics of 161 cases of excision and the 
mortality among these was as follows: 

Primary operation 93 per cent. 

Intermediate operation 96 . 6 per cent. 

Secondary operation 63 . 4 per cent. 



GUNSHOT WOUNDS OF JOINTS 347 

The statistics of Gurlt and Langenbeck collected in the German 
wars of about the same period give results only a trifle better. 

Notwithstanding the high mortality observed by Otis, this author 
boldly advocated primary excision in all uncomplicated cases of shot 
fracture of the head or neck of the femur. He wrote at a time when 
expectant and conservative methods of treatment were invariably 
followed by sepsis and death, or complications that ended in prolonged 
suffering. Under our present methods of treatment we no longer 
advocate primary excision for uncomplicated fracture of the head 
or neck of the femur. It has been almost entirely supplanted by 
conservative methods. Out of three cases in the Spanish- American 
War, 1 and eight in the Anglo-Boer war (Stevenson) so treated, there 
were three deaths — a mortality of 27.2 per cent. Although this 
number is small to predict the outcome in other wars, we confidently 
believe that it will serve as an index of the official reports of the 
Manchurian and Turko-Balkan campaigns, when these are published. 

Intermediate Excision. — The mortality is rated so high when the 
operation is performed at this stage in the clinical history of such 
cases that it should be seldom resorted to. It may be contemplated 
in cases which might have suffered excision primarily, when the latter 
was delayed for insufficient diagnosis, or proper opportunity to control 
one's surroundings; but in such cases it will always be wiser to adopt 
conservative measures such as the removal of loose fragments of bone, 
free irrigation, drainage, and the careful use of antiseptic materials. In 
this way one will often succeed in arresting an active inflammatory 
process or in tiding the case over to a suitable time for a secondary 
excision. 

Secondary excision is practised when efforts at conservation fail 
through the introduction of sepsis into the wound, and when all 
efforts to stay the inflammatory process have been unavailing. In 
such cases necrosis of bone is common, fragments primarily attached 
have become loose, and the case requires thorough exploration and 
excision to remove all diseased tissues properly. 

There were but eleven secondary excisions recorded in our Civil 
War by Otis, with a mortality rate of 72.7 per cent. The number 
of cases for this great war is small, but it is accounted for by the fact 
that comparatively few patients survived injuries involving the hip- 
joint until the time for secondary excision had arrived. 

Otis observes (1883) that since the Civil War the operation of exci- 

1 Report S. G. 0., U. S. A., 1899-1901. 



348 GUNSHOT WOUNDS 

sion of the hip for shot injury has been practised five times in the 
U. S. Army and once in the U. S. Navy and this aggregate of six cases 
gives four recoveries. We took one of these army cases off the field 
during an Indian campaign in Wyoming in 1876 along with a number 
of others" seriously wounded. The following is an abstract from the 
history 1 of the case : Sergeant William J. Linn, Co. M, 4th Calvary, was 
shot Nov. 26, 1876, with a 50-caliber conoidal bullet weighing 412 
grains, in a battle with Indians. The ball passed through the right 
hip-joint while he was resting on his right knee and left foot in the act 
of firing his carbine. A plaster-of-Paris bandage was applied to the 
injured limb at once, including a spica around the waist, and the next 
day he was moved on a travois through a mountain region without 
roads, in excessively cold weather. We reached our base of supplies 
on the third day. The plaster-of-Paris cast was here removed, and 
after establishing free posterior drainage a new plaster-of-Paris cast 
was securely applied as before and the patient was carried by ambu- 
lance five days over a country devoid of roads, in what was then known 
as the most inhospitable region of our country, in cold weather that 
hovered around zero most of the time. Lieutenant John Van R. 
HofT, Medical Corps, now Colonel U. S- Army, retired, who reported 
the case successfully performed secondary excision of the hip-joint 
ten months later. He found the head of the femur loose in the joint 
cavity. It had been severed from the neck by the bullet, and this with 
other necrosed bone including the upper end of femur just below 
the great trochanter, was entirely removed. Two years later this 
soldier had so far recovered the use of his limb that he got along with- 
out a crutch, and only used a walking cane on long walks. 

We believe this case was tided over the active inflammatory 
period during transport because of good drainage and thorough im- 
mobilization with plaster of Paris. Our attempts at antisepsis in that 
time were very crude, and under the conditions then prevailing sepsis 
was unavoidable. 

The best method of performing excision of the hip need not occupy 
us here. Generally speaking the posterior incision extending from a 
half-inch below the anterior superior spine of the ilium and passing 
downward over the most prominent part of the great trochanter will 
afford better drainage and in cases in which the greater trochanter is 
implicated the opportunity to observe the extent of lesion and remove 
loose fragments makes this incision particularly advantageous. 

1 Med. and Surg. History War Rebellion, Surg. Vol., Part III, p. 123. 



GUNSHOT WOUNDS OF JOINTS 349 

The after-treatment is the same as that for chronic hip-joint cases 
generally. 

Amputation of the Hip -joint. — The results of all amputations at 
the hip-joint in military practice were collected by Otis, including the 
sixty-six cases which occurred in our Civil War. The mortality is 
thus referred to by the great author — "we thus arrive at an aggregate 
of 250 cases of exarticulation at the hip as the present status of this 
grave mutilation in military surgery, with twenty-seven recoveries, 
222 deaths, and one example with unknown result or a mortality of 

89.1 per cent." Of twenty-five primary amputations among the 
sixty-six cases in the Civil War death occurred in twenty-two cases, a 
mortality of 88 per cent. The operation in the intermediate stage 
in twenty-three cases gave the usually high mortality — 100 per cent., 
and 77.7 per cent, in nine cases in the secondary stage. In thirteen 
of the twenty-two fatal cases in the first group the wounds were in- 
flicted by cannon shot, shell fragments or other large projectiles 
causing in all instances extensive mutilation, and noted in words like 
the following: shattering of the femur high up and mangling of soft 
parts, tearing away of muscles and comminuting the neck and tro- 
chanters, inflicting terrible laceration of the upper and exterior part of 
the thigh, comminuting the upper third of the femur and fracturing 
the tuberosity of the ischium, etc., etc. In six instances it was 
necessary to perform primary disarticulation at the hip because of 
graver injuries to the femur conjoined with lesions of the femoral 
artery. Of the three who recovered the first was struck by a frag- 
ment of a 24-pounder shell crushing the trochanters and neck of femur 
and wounding the femoral artery, the second received a conoidal ball 
fracture of the right femur, fissures extending into neck quite within 
capsular ligament, and the third suffered comminution from a round 
ball and buck, comminuting the femur just below trochanters. 

It is interesting to note that of nine reamputations at the hip-joint 
for osteomyelitis and other secondary complications there were but 
three deaths — a mortality of 33.3 per cent. The reamputations were 
rendered necessary in cases which had suffered amputation in the 
middle and lower third of the thigh. 

In three secondary disarticulations in the Spanish-American War 
there was one death and in the Anglo-Boer War Stevenson reports 
thirteen cases with eight deaths, making an aggregate mortality of 

56.2 per cent, for the sixteen cases in these two wars. 

Shock and hemorrhage cause the great mortality in primary ampu- 



350 GUNSHOT WOUNDS 

tation of the hip-joint. The environments in active campaign rather 
forbid the risk attendant upon such a marked capital operation. The 
rule of the present is to postpone all cases, when possible, to the secon- 
dary stage and at a time when the environments are more propitious. 

In those cases of injury by shell fragments which are apt to destroy 
the limb, Langenbeck recommended removal of the head of the former 
primarily, leaving amputation of the limb to be practised later. In 
this way the extreme additional shock of amputation is avoided. With 
the resources of modern surgery at hand, except in very extensive 
injuries of the soft parts, the management of the cases should be 
directed toward saving the limb, and should this prove unavailing 
secondary amputation can be practised later with far less danger to 
life. 

Wounds of the hip-joint in recent wars are necessarily few in 
number. We await the official reports from the Manchurian and 
Turko-Balkan campaigns with confident hope of renewed achievements 
for modern surgical practice. 

Gunshot Wounds of the Knee-joint. — With the use of the old 
armament wounds of the knee-joint numbered 28.7 per cent, of all 
joint wounds in military practice and 3 per cent, of all war wounds. 
The frequency of gunshot of this joint is now less than formerly be- 
cause of modern tactics which require men to fight under cover. Out 
of 4756 gunshot wounds of all parts tabulated by the Surgeon-General 1 
in the Spanish- American War, injuries to the knee-joint constituted 
about 23 per cent, of all joint wounds, and 1/2 per cent, of wounds 
of all parts. 

For purposes of study gunshot wounds of the knee-joint are 
divided into: (a) simple perforation of the synovial sac without ac- 
companying lesion of any bone; (b) injury to the joint with lodged 
ball; (c) injury to the joint exhibiting guttering of the articular ends 
of the bones; (d) complete perforation of the articular ends of bones 
in different directions; (e) implication of the joint by Assuring and 
comminution of the bones entering into its formation. 

(a) Simple perforation of the synovial sac is known to be of more 
frequent occurrence now than formerly. During the days of larger 
calibers it was necessarily infrequent, but so late as the Civil War, 
under the designation of peri-articular wounds, Otis collected 351 
cases with a mortality of 29.9 per cent. Of the 351 cases, he estimates 
that 255 cases suffered direct involvement of the capsule without 

1 Reports of S. G., U. S. Army, for 1398-99. 



GUNSHOT WOUNDS OF JOINTS 



351 



fracture " and that in ninety-six cases the projectiles did not injure 
the joint, which was opened by secondary traumatic arthritis." 
Considering the difficulties of diagnosis which prevailed at that time 
and the fact that many of those who got well were not actually verified 
as simple synovial perforations, it may be admitted with propriety 
that some of Otis' cases were complicated by at least slight osseous 




Fig. 135. — Radiogram showing postero-anterior and lateral views of knee in case of Pvt. 
William R. Barret, 29th Co., U. S. Coast Artillery. Exposure was made in 1909. This man was 
shot prior to enlistment with a .38 cal. Smith and Wesson revolver and the presence of the missile 
in the knee was not detected until he had been in the service some time. The washers were used as 
localizers. Army Medical School collection. 

lesions. Nevertheless it has been definitely ascertained by actual ex- 
perience and by experiment that a bullet can traverse the joint, when 
the leg is in any position except complete extension by entering below 
the patella and ranging antero-posteriorly. It thus finds sufficient 
room to pass through the intercondyloid notch without inflicting frac- 
ture of the articular ends. There is sufficient space from side to side 



352 



GUNSHOT WOUNDS 



under the extensor muscles for a ball of moderate diameter to penetrate 
the reflection of the synovial membrane in that region. Again, when 
the knee is slightly flexed, the tibia and condyles are widely separated 
and there is ample space for a bullet to traverse the synovial sac in 
the anterior third of the joint behind the patella. Examples such as 
those mentioned were noted with the larger calibers by military sur- 
geons in all wars and they will be far more frequent with the use of 
reduced calibers henceforth. Peri-articular wounds with involvement 




Fig. 136. — Pvt. Roman Carinom, Co. 18th Philippine Scouts, wounded by what was thought 
to be a reduced caliber rifle bullet in engagement with Moros in 1912. Missile which appeared to be 
part of the core of an armored bullet was removed by opening joint. It was imbedded in articu- 
lating surface of outer condyle. Army Med. School collection. X-ray Laboratory, Division Hos- 
pital, Manila, P. I. 



of the synovial membrane will be as frequent as formerly. Stevenson 
states that wounds of the synovial membrane alone were fairly common 
in the Boer War. 

(b) Injury to the Joint with Lodged Ball. — Projectiles have been 
known to lodge in the joint cavity without implicating bony structures. 
Balls lodge in or about the knee-joint more often than in any of the 
articulations. They are at times found in the joint but more often 
they are located in the epiphyseal ends of the tibia or femur. (Fig. 



GUNSHOT WOUNDS OF JOINTS 353 

135.) Lodged balls in or about the knee formerly proved a ser- 
ious complication in gunshot of this articulation (Fig. 136). Much 
harm was done in attempts to explore for the missile, and the search 
was more often futile. Under our present methods of diagnosis with 
the aid of the X-ray, knee cases complicated by lodged balls are 
promptly relieved. Out of ninety-five gunshots of the knee in the 
Anglo-Boer War lodged bullets were removed from ten cases (Spencer). 

(c) Injury to the joint exhibiting guttering of bone is one of the 
frequent lesions about the articular ends of the femur and tibia with 
the use of reduced calibers. The lesion may be superficially disposed 
about the contour of the joint ends, or there may be a superficial 
grooving of the joint surfaces proper, with spicules of bone protruding. 
The amount of lesion in any wound exhibiting grooving will necessarily 
be proportional to the sectional area of the bullet. Grooving by the 
modern bullet is clean-cut except in shots delivered at the proximal 
ranges. Here there may be short fissures radiating from the track 
of the bullet with detached particles of bone in the joint or in adjacent 
tissues. 

(d) Complete perforation traversing the joint in different direc- 
tions were occasionally noted in the days of the older calibers, but they 
have become especially common since the adoption of steel-jacketed 
rifle bullets, and they are typically shown in the bony structures of 
the knee. In the mid ranges clean-cut perforations are the rule through 
the patella, condyles of the femur and the epiphyseal end of the 
tibia. Proximal shots from the new military rifle which perforate near 
the joint surfaces may exhibit fissures opening on the joint surfaces, 
but when present they are more apt to be subperiosteal in nature. 
As already stated perpendicular shots, which cross the joint by the 
shortest route inflict a minimum amount of injury and are attended 
with the best results. 

(e) Implication of the joint by Assuring and comminution of the 
bones entering into its formation was the common lesion inflicted by 
shell fragments and the old lead rifle bullets of former times. In 
modern wars they are still observed as a result of shell fragments and 
shrapnel balls. The amount of lesion is always proportional to the 
sectional area and velocity of the projectile on impact. A shot from the 
larger calibers at proximal ranges which strikes the lower end of the 
femur just above the intercondyloid notch is apt to detach the condyles 
from the shaft as a result of deep fissures extending upward. The di- 
aphysis of the tibia just before it unites with the upper epiphysis is 

23 



354 GUNSHOT WOUNDS 

made up of hard compact bone, so that shots at high velocity and 
sufficient sectional area near the epiphyseal junction will at times com- 
minute the epiphysis into the joint, producing isolated fragments of 
varying sizes. The tendency, however, with armored bullets of 
reduced calibers is to make perforations in the epiphyseal ends of 
bones, and this tendency is still observed in the diaphysis adjacent 
to the knee-joint whether the bullet traverses the upper end of the tibia 
or lower end of the femur. 

Diagnosis. — The diagnosis of wound of the joint will rest largely 
upon a study of the location of the apertures of entrance and exit. 
Effusion of blood into the joint, swelling, pain and inability to move the 
knee, are all valuable signs. Fracture will be attended by crepitation. 
Displacement of bony fragments when present is an absolute sign. 
The amount and kind of lesion and the presence of lodged missiles 
will have to rest on X-ray evidence. 

Treatment. — The treatment employed in preantiseptic times was 
(1) amputation, (2) conservation, and (3) excision. Among these 
methods amputation was the rule adopted in our great Civil War, and 
the surgeon who adopted any other course in any gunshot wound of the 
knee was considered to be remiss in his duty to his patient. Conserva- 
tion and excision were only practised in those cases where the patient 
refused amputation. The limb was sacrificed even in those cases where 
the joint capsule alone was supposed to be injured. In 313 cases of 
this kind treated without operation the mortality was 22 per cent. 
(Otis). 

When antisepsis was first adopted our earliest observations of its 
value in military field practice were brought forth by Reyher and Von 
Bergmann in the Russo-Turkish War of 1877-78. Reyher reported 
eighteen primary aseptic cases of wounds of the knee, regardless of the 
extent of joint involvement, dressed antiseptically, of whom three 
died, a mortality of 16.6 per cent. The treatment was entirely con- 
servative. He employed weak carbolic-acid irrigations in severe 
cases while the simple cases were cleansed and dressed with wet carbolic 
gauze. Those who got well recovered with movable joints. 

Von Bergmann used the same antiseptic details in fifteen cases 
of gunshot fracture of the knee with fourteen recoveries, two of the 
successful cases having suffered amputation. The only fatal case 
was one in which amputation was practised. Although no reference is 
made as to the utility of the limbs in the non-amputated cases, it is 
presumed that they got well with movable joints. Since the ex- 



GUNSHOT WOUNDS OF JOINTS 355 

perience of Reyher and Von Bergmann was obtained prior to the 
introduction of the new military rifle, their cases must represent 
injuries by the old leaden conoidal bullet of about forty-five calibers, 
weighing approximately 480 grains, and having an initial velocity of 
about 1300 f.s. 

Grouped together we find that the cases of Reyher and Von 
Bergmann which suffered lesion from similar weapons and which were 
treated antiseptically have an aggregate mortality of 11.1 per cent. 

The statistics recorded by Otis show that in 868 gunshot fractures 
of the knee in the Civil War treated by conservation there was a 
mortality of 60.6 per cent. Amputation as a mode of treatment was 
practised in 2431 cases. When amputation was performed through the 
joint the mortality was 56.6 per cent, and when it was done through 
the lower third of the femur the mortality was 53.6 per cent. 

Compared to the results obtained in the Civil War in preantiseptic 
times after lesions of the old armament, the results of Reyher and 
Von Bergmann with practically the same kind of wounds, aided by the 
use of antiseptics, stand out as a great triumph in favor of modern 
methods. 

The cases treated in the Spanish-American War and Philippine 
Insurrection from 1898 to 1902 numbered seventy-seven all told with 
six deaths, one of the deaths was due to tetanus. If this is excluded 
from the list it gives seventy-six cases with five deaths — a mortality 
of 6.5 per cent. These wounds were due to all kinds of fire-arms in- 
cluding large- and small-caliber hand weapons, shell fragments, and 
shrapnel. 

There were ninety-five gunshots of the knee-joint in the Anglo- 
Boer War with a mortality of 4.2 per cent. Amputation was performed 
in 11.5 per cent, of the cases, all of which were injured by shell frag- 
ments, and according to Stevenson the fatalities were confined to 
septic cases from severe shell fractures. We can surmise from this 
report that the other knee-joint injuries in which no deaths occurred 
resulted from hits by the projectiles of hand weapons, mostly reduced- 
caliber Mausers. This evidence agrees with our experience at the 
battle of Santiago. Out of seventeen cases of gunshot injury by 
the reduced-caliber Spanish Mauser there was not a death, fourteen 
of the men hit recovered so that they were restored to duty, and three 
were discharged on surgeon's certificate of disability or otherwise 
disposed of. 

The results after gunshot of the knee-joint by reduced-caliber bul- 



356 GUNSHOT WOUNDS 

lets, and the use of modern methods of treatment point in a most 
striking manner to the beneficence which has come from antisepsis 
and the humane injuries from steel-jacketed bullets of the modern 
military rifle. 

Conservation in the wars of the present day should be practised 
in all cases in which the lesion of the knee has resulted from reduced- 
caliber bullets. This rule has been adopted as a result of observation 
of the nature of the lesions inflicted in war, and in the experimental 
field as well. The humane character of joint wounds, especially those 
of the knee, was foretold long before any war was fought with the new 
armament, and the work of the experimenters, which was so unjustly 
assailed by critics here and there, is nowhere more significantly brought 
out than we find it in the knee-joint. 1 

In the more simple cases no attempts at exploration should be made 
except for pieces of clothing or foreign bodies. Wounds of the patella 
alone are generally in the nature of a perforation and when fragmented 
the fragments are usually well held together by ligamentous tissue so 
that no surgical operation is required. In so far as the patella alone 
is concerned, the treatment is the same as practiced in shots which in- 
clude the synovial membrane or the osseous tissues of the joint proper. 

When splintering and fragmentation of the ends of the tibia and 
femur are marked as shown by palpation it may become necessary to 
explore the joint for the removal of loose pieces of bone. This should 
be done by laying open the joint or by enlarging the wound of exit. 
If it is necessary to obtain sufficient room for purposes of diagnosis, 
an incision may be made on one or the other side of the patella, or a 
horse-shoe flap, convexity downward, should be raised, as recommended 
in formal excision of the knee. After dividing the ligamentum 
patellae, the lateral and crucial ligaments, ample room will be found 
both for purposes of diagnosis and such operative interference as may 
be deemed necessary. After removing loose pieces of bone, lodged 
missiles, or other extraneous matter, the synovial sac and wounded 
surfaces should be irrigated with a weak antiseptic solution, the 
incised surfaces should next be brought together with appropriate 
sutures, and the necessary drainage provided for. The latter should 
remain in place from thirty-six to forty-eight hours. The limb should 
next be dressed and immobilized upon a fenestrated wire or plaster- 
of-Paris splint. 

If suppuration supervenes prompt incision and ample drainage will 

i Report S. G., U. S. A., for 1893. 



GUNSHOT WOUNDS OF JOINTS 357 

be required. If the case becomes septic, and shows no signs of 
improvement the surgeon will have to be guided largely by the eviron- 
ments at hand. Where persistent and watchful care cannot be main- 
tained as in enforced transport, the patient's chances will be better, 
if amputation through the lower third of the thigh is resorted to. 

Anchylosis more or less complete is the rule in knee cases that 
recover after extensive comminution, or in cases complicated by 
suppuration. 

Primary excision of the knee has never been a favorite operation 
in military practice. Otis, MacCormac and other noted surgeons do 
not recommend it. It should only be resorted to in the case of shell 
wounds with much fragmentation, in patients who positively refuse 
amputation. The old-time death rate from excision of the knee was 
largely from causes which are at present partly avoidable. In thirty- 
two recorded cases by Otis in our Civil War the mortality was 86.6 
per cent. In other wars in the preantiseptic era the mortality ranged 
as high as 90 per cent. We have no statistics to show the results of 
excision under modern surgical conditions, but we have reason to believe 
that formal primary excision of the knee under proper environment 
may yet find favor in military practice. 

Intermediate and Secondary Excision. — The fatality for excision 
in the intermediate stage was very great in the Civil War, only one 
recovery having been recorded in thirteen cases. The operation would 
doubtless be as fatal now but it is no longer recommended. Secondary 
amputation affords a far better chance of life. Secondary excisions 
find no more favor in military than they do in civil practice. The 
operation was done in two instances in the Spanish-American War 
with one recovery. 

Primary amputation for injury to the knee-joint is only recom- 
mended in cases of extreme traumatism of the bones, soft parts and 
large vessels. Such injuries are usually sustained by shell fragments, 
and the patients often die of shock and hemorrhage before reaching 
hospital care. The limb should be amputated through the joint or the 
lower third of the femur depending upon the amount and condition of 
the material for flaps. Statistics favor amputation at the latter point. 

Colonel Gray 1 states that in the earlier part of the present war the 

result of treatment in gunshot wounds of the knee among those who 

recovered was marked by ankylosis in the majority of cases. The 

period of convalescence was usually most painful and precarious. 

x Op. cit. 



358 GUNSHOT WOUNDS 

These results are attributed to erroneous ideas of treatment which have 
been abandoned. Among the errors mentioned are: (1) the belief 
that suppurative infection of the joint demanded free and prolonged 
drainage; (2) the use of drainage tubes, more or less large in size, 
inserted deeply into the various recesses of the joint; and (3) the use of 
strong antiseptic treatment which was inimical to a restitutio ad inte- 
grum, because the deleterious action of the antiseptics destroyed the 
synovial membrane and cartilage, forming a fruitful source of 
ankylosis. 

In lieu of the foregoing line of treatment the following factors are 
now insisted upon: (1) wounds of the joint that are apt to become 
septic demand mobilization; but few such cases when received from the 
front are provided with properly applied splints. This important 
lapse in treatment is apt to favor the entrance of sepsis to a knee pre- 
viously infected, and again there is danger that it might stimulate a 
virulent, diffuse inflammation instead of a mild, localized one. It is 
insisted upon that during the treatment the splint be retained two or 
three weeks at least. Later, gentle passive movement is recommended; 
(2) formerly, foreign bodies were removed " only if they led to trouble; " 
now only those embedded in bone outside the joint are left undis- 
turbed, all others are removed whether they are the source of im- 
mediate trouble or not; (3) excision of the wound in the skin and super- 
ficial tissues is now a routine process. 

The present treatment is summarized as follows: Excise wounds 
of the skin and superficial soiled or necrotic muscle and fascia. En- 
large the wound freely if necessary. Remove foreign bodies, pre- 
viously localized by X-rays, after possible enlargement of the 
synovial membrane. Flush the synovial cavity with 5 per cent 
saline solution. In very acute cases make fresh incisions. Trim 
the edges of the wound in the synovial membrane; suture if the 
sepsis is not acute. Insert drainage tube down to but not through 
the wound in the synovial membrane. Fill the rest of the wound 
firmly with " tablet and gauze" dressing. Inject formalin, glycerine, 
or ether, through the fresh puncture. Clean and redisinfect the sur- 
rounding skin. Apply superficial dressings and light bandage. Im- 
mobilize in suitable splint. If this fails, free arthrotomy, and possibly 
amputation should be employed. 

The results are stated in ten cases in which the old treatment 
was practised in some, and the new in a few others, and thirty-six cases 
by the new method as follows : 



GUNSHOT WOUNDS OF JOINTS 359 

Per cent. 

cases 

Deaths in spite of amputation 2 20 

Amputation 3 30 

Ankylosis 1 10 

Doubtful 1 10 

Free movement when discharged 3 30 



10 100 

Death in spite of amputation 

Amputation 3 8.33 

Ankylosis 3 8.33 

Doubtful 2 5.55 

Free movement when discharged 28 77.77 

36 99.98 



In looking over the thirty-six cases detailed briefly for the most 
part, the reviewer finds that twenty-seven were due to shrapnel or 
shell fragment, and nine resulted from bullets or missiles the nature 
of which is not specified. To have cured twenty-eight of these with 
movable joints is an achievement that is heartily commended, con- 
sidering the nature of the missiles causing the wounds. 

The author insists on mobilization as a prime factor in all knee- 
joint wounds. The treatment is not new since it is an established mode 
of treatment in surgery as a rule, and military surgery in particular. 
We have taught the value of immobilization for years, not only in 
joint injuries and fractures from gunshot, but in all gunshot wounds 
including those of soft parts even where immobilization is impossible. 
Fixation of wounded parts plays a great role as a prophylactic against 
the development of infection. When enforced transportation is neces- 
sary, as often happens in military practice, it adds to the comfort of 
the patient in keeping down pain, it prevents the recurrence of hemor- 
rhage, and it also favors early healing. 

T. Turner in the Bull. Acad, de Med. Paris, 1915, No. 23, gives an 
interesting account of his recent visit to the hospitals and he states 
that gunshots of the knee by rifle bullets generally heal kindly, but 
those from shrapnel and shell fragments undergo suppuration and end 
in ankylosis after months of convalescence. Tuffier was surprised 
during his recent visit at the front to hear the operating surgeons pro- 
claim the doctrine that all infected gunshots of the knee should be 



360 GUNSHOT WOUNDS 

treated by amputation. Of 200 amputations through the thigh for 
this cause, 30 of them were for simple perforation of the articulation 
by the rifle bullet. Resections had been practised but seldom. He 
performed resection of the knee in four cases in which amputation 
appeared to be the only resource, with excellent results. 

The lesions found in the knee were a source of surprise. The broken 
femur, tibia, and knee-cap were not attended with any usual conditions, 
but the synovial membrane, and all of its folds and recesses, was as 
thick as the two hands together, very much infiltrated by inflammatory 
products, red and lardaceous, presenting the appearance of a tuber- 
cular synovitis. This condition went far to explain the intensity and 
duration of the septic process in knee-joint cases. Since 10 per cent, 
of amputations of the thigh have to suffer re-amputation or other 
secondary operations about the stump, the author advises resection 
in preference to amputation. 

Gunshot Wounds of the Ankle-joint. — Among war wounds of the 
foot by gunshot, those confined to the ankle-joint aggregate one-third 
of the whole. Like most of the wounds of joints, gunshot injuries of the 
ankle are divided into those of the articulation without and with 
bone involvement. The former were designated under the term peri- 
articular wounds by Otis, of which there were thirty-seven cases in 
the Civil War, and 1711 of those with bone lesion. The peri-articular 
wounds, as designated by Otis, included injury to the tissues immedi- 
ately surrounding the joint, like the vessels, nerves, tendons, and mal- 
leoli, without involving the joint cavity, and also cases in which the 
synovial sac of the joint was penetrated without bone lesion. He 
does not state how many of the thirty-seven peri -articular wounds were 
of the latter class. We have demonstrated experimentally on the 
cadaver that it is possible for a reduced-caliber bullet to penetrate 
the synovial sac transversely in front or behind on a line with the ar- 
ticular surfaces of the tibia and astragalus without injuring bony parts. 
On account of its superficial position, wounds of the synovial membrane 
of the ankle alone are generally admitted to be of rare occurrence, 
much more so than we find in either the shoulder, hip, or knee. 

Gunshot Fracture of the Bones of the Ankle-joint. — The sectional 
area and velocity of the projectile will have great influence upon the 
osseous lesion in gunshot of the ankle-joint. The projectiles of the 
days of the Civil War inflicted injury that was more often marked 
by comminution, detached fragments, and extensive laceration of 



GUNSHOT WOUNDS OF JOINTS 361 

the ligaments, tendons, etc., about the joint. Wounds of the astrag- 
alus by reduced-caliber bullets generally groove its superior, inferior, 
and lateral surfaces with few fissures, the latter being more often sub- 
periosteal or sub-cartilaginous. When the body of the bone is hit 
the lesion is marked by a clean-cut perforation in the mid ranges. If 
the projectile is animated by a high velocity, the perforation will be 
attended with fissures extending in the substance of the bone, and when 
the bullet makes an impact at its maximum velocity the bone may be 
pulverized into minute fragments, the wound of entrance and exit 
being filled with bony sand. The lower end of the fibula, viz., the 
external malleolus, which consists of epiphyseal tissue, may be grooved 
or perforated with or without fissures extending into the joint. The 
bone opposite the joint higher up is very hard and brittle. Shots at 
this point in the fibula are apt to show considerable comminution in- 
volving the joint cavity. Shot injuries located in the joint end of the 
tibia, viz., in the epiphyseal tissue which includes the lower end of the 
internal malleolus and about 1/3 inch of the lower end of the bone 
proper, are prone to show the same tendency to clean-cut perforation 
that one observes in the joint ends of bones generally, but lesions in 
this limited area are not often seen. The bone involvement generally 
includes the tibia above the epiphyseal line where the compact bone 
is hard and the resulting lesion will show long fissures extending 
upward and downward into the joint. The amount of comminution 
or fragmentation will be proportional to the sectional area of the pro- 
jectile and the amount of energy delivered on impact. 

Lesions from shrapnel and shell fragments will generally be ex- 
treme in character and those from the latter especially will require 
immediate amputation as a rule. 

The treatment of gunshot of the ankle will be taken up under 
conservation, excision and amputation. 

Conservation. — About the time of our Civil War military surgeons 
generally followed the teachings of Larrey, Thompson, Guthrie and 
others which favored amputation almost exclusively in gunshot of the 
ankle. The wounds of those days showed characteristics that favored 
the development of sepsis, and, in a location so beset with dirt as the 
ankle, the dangers of the virulent infections were especially marked. 
Guthrie, in his treatise on Gunshot Wounds, states that " Wounds of 
the ankle-joint from gunshot are extremely dangerous, and in general 
require amputation." Thompson, in his report of observations, etc., 
after the battle of Waterloo, states that "Wounds in which musket 



362 GUNSHOT WOUNDS 

balls have passed through or lodged in the ankle-joint almost all require 
immediate amputation. These injuries by giving rise to high degrees 

of inflammation not infrequently prove fatal. Among a 

great number who had survived the fever we saw but few in whom 
secondary amputation was not required, and in the cases requiring it 
this operation was far from being so successful as the primary ampu- 
tation had been." The expressions of Larrey are all to the same effect. 
Our surgeons in the Civil War avoided conservation for similar reasons. 
In 1711 gunshot fractures of the ankle-joint reported by Otis but 518 
were treated by this method. Generally the less severe cases were 
selected for the conservation method and even then the mortality rate 
was 19.5 per cent. 

Among those who recovered from gunshot injury of the ankle after 
conservation in the preantiseptic era the results on the score of utility 
of the foot and limb were generally bad. The foot was more often 
ankylosed in the tibio-astragalar articulation and oftentimes, of more 
serious import, the ankylosis extended to the astragalo-calcanean artic- 
ulation. There were deviations of the foot laterally or antero-poste- 
riorly, the loss of tendons, necrosis, and long-continued inflammation in 
and about the tissues of the joint, persistent swelling and pain were 
among the remote disabling effects that made life more or less of a 
burden. 

We have reason to expect better results hereafter under modern 
conditions. Still, as already stated, wounds in the ankle are located in 
rich soil for the development of septic microbes. In spite of the ample 
preparation that a great civilized government can make against the 
occurrence of sepsis in war wounds, infection occurred in twenty-eight 
out of the forty ankle-joint wounds reported from the Anglo-Boer War. 1 
It is, however, gratifying to note that there was no death reported. 
Thirteen of the cases were marked by perforation, and nine among 
these were aseptic. They all made rapid recoveries under a conserva- 
tive mode of treatment, but the majority showed some limitation of 
movement when invalided home. The removal of bony fragments 
among the thirteen cases exhibiting perforation was at no time 
required. Incisions were made in two cases, and a lodged ball was 
extracted from the substance of the astragalus in one. In twelve 
other cases operative treatment was resorted to for the removal of 
fragments of either the tibia, fibula, or tarsal bones. Eleven of these 

1 Gunshot Wounds of Joints by Lt.-Col. S. Hickson, R. A. M. C, in Stevenson's 
Report. Harrison & Sons, St. Martin's Lane, London, 1905. 



GUNSHOT WOUNDS OF JOINTS 363 

cases were septic. There was considerable limitation of movement in 
some of the cases and absolute fixation in others. 

The Surgeon-General, U. S. Army, for the four years 1898 to 1901, 
which includes the period of the Spanish-American War and Philippine 
Insurrection, reports twenty-six gunshot wounds of the ankle-joint 
with two deaths. Eleven of the men were restored to duty, and 
thirteen were discharged on surgeon's certificate of disability. They 
were all treated conservatively with one exception, in which amputa- 
tion became necessary. We may take the cases of the Spanish-Ameri- 
can and Anglo-Boer Wars as an index of the results we are to expect 
in the majority of ankle-joint injuries hereafter under modern condi- 
tions. Conservation is indicated in the large majority of the cases, viz., 
in all except those in which the bones and soft parts have suffered such 
extreme traumatism as to necessitate immediate amputation. The 
rule of treatment now is to dress the wound antiseptically and to 
employ fixation at once. If fragments have to be removed this can 
usually be done through the exit wound, as it is larger and, when 
necessary, it can be incised to give more room. Only loose fragments 
should be removed. Severed tendons should be united by catgut or 
silkworm-gut suture. The wound should next be irrigated, and a 
drain to remain thirty-six to forty-eight hours put in place. 

Fixation is best accomplished with plaster of Paris. The splint 
should extend from above the knee to the toes to properly immobilize 
the tibia and fibula. Plenty of window space opposite the ankle 
should be cut away to permit easy access to the wounds for redressing. 

When the wound becomes infected, the inflammatory process will 
generally be arrested by establishing good drainage through free in- 
cisions, and the use of frequent irrigations with germicidal solutions of 
a necessary strength once or twice daily. The after-treatment in the 
way of massage, movement of the toes, rubbing, and faradization of 
muscles will do a great deal toward restoring the use of the ankle. 

Excision of the Ankle-joint. — This operative measure is only 
mentioned here to be condemned. It finds no place in either the 
primary, intermediate or secondary stages of ankle-joint lesion from 
gunshot. In addition to the fact that the results as far as the utility 
of the limb were extremely bad in our Civil War, according to Otis, the 
mortality of excision of the ankle was one-third greater than that 
observed after the conservative plan of treatment. The operation 
was not popular in former times. Otis records but thirty-three cases in 
the Civil War with nine deaths — a mortality of 29 per cent. The 



364 GUNSHOT WOUNDS 

results in the Franco-German War out of fifty cases gave an aggregate 
mortality of 43 per cent. In the recoveries recorded by Otis the greater 
number suffered from painful and swollen joint; fistulse were not in- 
frequent, and the patients almost invariably had to walk with the aid 
of crutches. As a general result, in excision of this joint, the foot is 
often turned in or out, or it is left in a state of equinovarus; the toes 
are deformed, and walking is not only painful but uncertain. Finally 
the results as to restoration of function are such that amputation in the 
lower third of the leg has hitherto been considered preferable. There is 
no account of excision of the ankle-joint in either the Spanish- American 
or Boer War. 

Amputation. — We have already indicated the conditions that 
demand primary amputation. They relate to extreme traumatism of 
bony and soft tissues with no hope of recovering the use of the ankle- 
joint or foot. These injuries are more often the result of hits by shell 
fragments, or wounds from shot-guns at close range, and they can also 
result from the effects of the modern rifle when it is discharged at 
contact or near by. Hickson 1 reports eleven cases of amputation out of 
forty injuries to the ankle-joint in the Boer War. The operation, as 
a rule, was rendered necessary on account of septic conditions associ- 
ated with comminuted fractures. Shell wounds figured in five of the 
cases and three of these were done on the field, but reamputation was 
necessary later on, from which the reporter lays emphasis upon the 
mistake which is often made of performing primary amputations at 
the front. 

Secondary amputation will be indicated when infection has 
thwarted attempts at conservation. The limb will have to be sacri- 
ficed at a point marked by sound tissues. 

1 Op. cit. 



CHAPTER XII 
Gunshot Injuries of the Diaphyses of the Long Bones 

The military surgeon is especially interested in gunshots of the 
diaphyses on account of their frequency, their varied character, the 
difficulties which they offer in transport, and finally, because they 
always figure among the serious wounds. 





Fig. 137. Fig. 13S. 

Fig. 137. — Radiograph showing oblique fracture by contact of Mauser bullet against outer side 
radius, from Spanish American War. (Borden.) 

Fig. 138. — Radiogram from Turko-Balkan War, 1912-13. Oblique fracture from very slight 
guttering of humerus by Bulgarian rifle bullet in a Turkish Infantryman at Lulu Burgas 1200 
meter range. War College collection. 

Contusions. — Lesions of this class are the result of direct injury 
by grazing, glancing or direct impact against bone from bullets or 
pieces of shell. The older works, like those of Guthrie, MacLeod, 

365 



366 



GUNSHOT WOUNDS 



Longmore and others made no reference to this form of injury. Lidell 1 
in our country was among the first to prominently call attention to 
such cases. He points out a fact observed by others since, that con- 
tusion of the diaphyses in the lower extremities is more prone to lead 
to necrosis and other bone complications than contusion of the diaphy- 
ses in the upper extremity, because the latter are more richly endowed 





Fig. 139. — Radiogram from Turko-Balkan 
War, 1912-13. Oblique fracture by Turkish rifle 
bullet at Burnar-Hissar, Oct. 30, 1912. War Col- 
lege collection. 



Fig. 140. — Radiogram from Turko- 
Balkan War, 1912-13. Transverse 
fracture by Turkish Shrapnel. Frag- 
ments of shrapnel ball lodged near 
elbow-joint. 



with blood supply. None of the cases cited by Lidell include the 
humerus, for instance, and Otis calls attention to the fact that our 
Army Medical Museum collection possesses but two examples of 
contusion in the humerus with other evidences of bone lesion, while 
such instances are not uncommon in the femur and tibia. Six of 
LidelPs thirteen cases were due to spent bullets lodged against bone 
and were removed through the wound. Five cases resulted from 
glancing bullets, one a grazing shot. One resulted in amputation, 
five died, and seven made more or less complete recoveries. 



1 Contusion and Contused Wounds of Bone with an account of thirteen cases 
by John A. Lidell, Surgeon U. S. Vols., Am. J. Med. Science, Vol. L, 1865. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 367 

Contusion of bone will be less likely to occur from the effects of the 
modern bullet unless it has lost its remaining velocity before impact, 
but it may occur from glancing shots at high velocity. Experiments, 
and observations in war have shown that the slightest contact by a 
bullet travelling at high velocity conveys a vibratory force to the bone 
of sufficient intensity to cause complete fracture. Such fractures are 
often attended with long fissures radiating some distance from the 
point of impact (Figs. 137, 138, 139 and 140). Whether this vibra- 
tory force is sufficient to cause contusion short of fracture when the 
bullet passes near a bone just short of contact has not been noted 
so far. 

The lesion in contusion of bone shows effusion of blood under the 
periosteum, the bone has lost its blood supply and in cases of direct 
injury by the ball there may be more or less destruction of the super- 
ficial part of the bone which adds to the existing lesion. The ele- 
ment of contusion and hematoma described augments the tendency 
to the development of infection, in which case, periostitis and 
ostitis are prone to occur, and when they do unless they are 
promptly and properly treated, terminal bone troubles, like necrosis 
with exfoliation of sequestra, or, worse still, osteomyelitis is liable 
to develop. In cases of injury adjacent to bone, whether fracture is 
present or not, if infection sets in, with the accompanying train of 
symptoms pertaining to inflammation in bone, the surgeon should 
regard the case as one of the acute bone lesions and treat it 
accordingly. 

Treatment of Contusion. — To forestall sepsis is the prime indica- 
tion in contusion of the diaphyses of the long bones. This is done 
by the use of antiseptic solutions upon the wound and the adjacent 
skin, or preferably painting with tincture of iodine before applying the 
first clean dressing. The projectile when lodged against bone should be 
removed as soon as it has been properly located. The wound should 
next be thoroughly irrigated with a weak antiseptic solution and then 
immobilized. If the temperature rises, with other symptoms of acute 
inflammatory process in bone, a free incision should at once be made 
down to the latter including the periosteum, to insure perfect drainage. 
If pus is found or if the pain and temperature continue, the compact 
bone at the point of injury should be trephined down to the medullary 
canal. If osteomyelitis is present, trephining at several points may 
become necessary. When the measures mentioned prove of no avail 



368 GUNSHOT WOUNDS 

and the symptoms persist, amputation should be performed at the 
joint next above the lesion. In a case of septic osteomyelitis of the 
femur Major Powell C. Fauntleroy, U. S. Army, and the author 
were able to arrest the disease process by amputating at the junction 
of the middle and upper thirds of the femur, after which the medullary 
canal remaining was curetted and swabbed with pledgets of lint on 
a probe, saturated with a solution of bichloride of mercury 1-1000. 

Gunshot fracture of the diaphyses of the long bones may be divided 
into (1) simple fractures and (2) compound fractures. 

Simple fractures were more frequent formerly as a result of impact 
against a bone by slow-moving shells or pieces of hollow shells of moder- 
ate size. Such fractures were also observed to occur from the large 
rifle projectiles striking at low velocity against a bony part with 
clothing or part of the equipment of the soldier intervening between 
the skin and the bullet. The force of impact in these cases more often- 
caused contusion of soft parts. The infrequency of simple fracture 
from such traumatisms may be estimated by the fact that Otis with 
his vast opportunities to collect accounts of all kinds of fractures from 
our Civil War mentions but nine cases of simple fracture without open 
wounds, and five of these occurred in the humerus. The amount of 
fracture and contusion of soft parts will depend on the volume and the 
force of impulse which is exerted by the projectile. The fractured 
bone may show comminution or simple fracture, and in the long bones 
multiple fractures have been noted. Otis gives the history of a case 
in a sergeant of artillery who was struck at the first battle of Bull 
Run "by a 12-pound shot which fractured the humerus at three dif- 
ferent points, but did not even bruise the skin." 

Simple fracture of the diaphyses of all the long bones as well as 
those of the metacarpal and metatarsal bones have been noted in the 
literature. It is doubtful if simple fracture with the use of the new 
armament will be noted as frequently hereafter. Large shot are mostly 
used against material now, and except on board men of war in naval 
combat and during siege operations they do not figure among the causes 
of war wounds. The treatment of simple fracture from gunshot is 
the same as that of simple fracture from other causes. 

(2) Compound fractures by gunshots are marked by an open wound 
of the soft parts leading into the foyer of fracture. The lesions in 
these osseous injuries were described in Chapter II, which deals with 
the characteristic features of gunshot wounds by different kinds of pro- 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 369 

jectile and they will not be referred to here except to state that the 
amount of traumatism in every fracture is coincident with the velocity 
of the projectile, its sectional area, and the resistance offered by the 
bone at the point of impact. The degree of traumatism will include 
grooving, perforation with short or long subperiosteal fissures, com- 
minution with detached fragments, and fissures which may extend 
above and below the fracture, as far as the adjacent joints. Gunshot 
fractures of the diaphyses are numerous in war hospitals. They form 
12 per cent, of all war wounds (Fischer). According to Otis those of 
the bones of the leg constitute 31 per cent, of all the fractures of the 
long bones; the humerus 28.4 per cent; femur 22.6 per cent, and the 
bones of the forearm 17.9 per cent. 

Follenfant 1 reports upon the variety of gunshot fractures exhibiting 
explosive effects in the Manchurian campaign, from which we find that 
operative measures for the removal of bone fragments were not numer- 
ous. The Kharbine statistics for 1904 record the removal of fragments 
in 184 cases out of 2845 fractures of the extremities. The fractures of 
the diaphyses showed long fissures on X-ray plates, as a rule. The in- 
fections were frequent, but not grave, and the amputations rendered 
necessary were comparatively few in number, not exceeding 5 per cent, 
for all fractures of long bones. Of thirty-six cases of tetanus observed 
at Kharbine in 1904 thirty-three occurred in gunshots of the extremities. 
The mortality after gunshot fractures was very small. Of 2845 cases 
only thirty-nine deaths are recorded and sixteen of these occurred 
among 478 gunshot fractures of the femur. The rule of treatment was 
almost entirely conservative. 

In the present European War, the observers have made careful 
notes of the effects of infection during the progress of the more severe 
wounds. In compound fractures especially Fleming 2 describes three 
phases as follows: 

The first phase occupies the first week. The discharge is a dark 
reddish-brown, foul-smelling fluid made up of blood altered to a greater 
or less extent by the growth of the fecal organisms which constitute 
the primal infection. The bacteria common to this phase are the 
spore-bearing anaerobes like the bacillus of tetanus and bacillus aero- 
genes capsulatus associated with streptococci and sometimes other 
organisms. 

1 Op. cit. 

2 Fleming, Alexander, On the Bacteriology of Septic Wounds. Lancet, Sept. 
18, 1915. 

24 



370 GUNSHOT WOUNDS 

In the second phase which lasts from the end of the first week to the 
end of the third week, the discharge loses its bloody character and be- 
comes purulent, the foul smell is less and tends to disappear. The 
spore-bearing microbes also tend to disappear but there is a gross in- 
fection from non-spore-bearing bacteria of fecal origin like strepto- 
coccus, B. proteus, etc. 

The third phase is seen after the first three weeks. In this stage the 
fecal microbes tend to disappear and they are replaced by pyogenic 
cocci, staphylococci and streptococci. 

There are other spore-bearing anaerobes besides bacillus aero- 
genes capsulatus and bacillus tetani present in the early phase of 
wounds. They are highly putrefactive and of unknown pathological 
significance. 

Treatment of Compound Fractures. — The treatment to be admin- 
istered at the first dressing station should consist of a field dressing and 
some form of temporary splint. 

The next opportunity for treatment will more often be in a field 
hospital where the equipment will permit a more careful examination. 
At this time the wound should be explored and cleansed, and such 
drainage operation instituted as may be deemed necessary. During 
the latter, septic matter, loose bone fragments and foreign bodies are 
removed. Thorough cleansing, and adequate drainage at this time will 
have great influence in forestalling severe sepsis, septic intoxication, 
cellulitis, secondary hemorrhage, and gas gangrene. During this 
cleansing process one has to decide upon the antiseptics to be used. 
Some surgeons advocate the use of strong antiseptics after the wound 
has been scoured with gauze or nail brush, while other surgeons prefer 
the use of milder antiseptics and frequent redressings. A third class of 
surgeons ignores the use of antiseptics entirely and relies upon free 
drainage and the use of hypertonic saline solution for the removal of 
septic matter. The latter method of treatment is very effective in the 
compound fractures from traumata in civil practice. The cases here, 
come under observation in an hour and often less, they are immediately 
treated by mechanical cleansing, drainage, and the use of saline solu- 
tion. The infection which is superficially disposed, is at once removed 
and the wounds very often heal without sepsis. In compound frac- 
tures by gunshot the infection is distributed at a distance by the lateral 
energy of the projectile and the task of ridding a wound of sepsis is 
not so easy. Still, if taken early, with plenty of drainage and watch- 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 371 

ful care, treatment by the use of saline will accomplish a great deal in 
warding off severe infections and their complications. 

Treatment by Hypertonic Solutions. — The patient should be pre- 
pared in the way suggested by Col. Gray and to which we have 
referred in the Chapter on General Treatment of Gunshot Wounds, 
Ch. V. After shaving and cleansing the surrounding skin, the wound 
is excised with a sharp knife being careful not to invade the septic 
area in the operation. The deeper parts of the wound may be removed 
preferably by cutting with scissors. The wound is next irrigated with 
saline solution. After the wound has been thoroughly cleansed with 
gauze swabs dipped in saline solution it is lightly packed with gauze, 
the latter extending to all ramifications of the wound. A drainage 
tube should be placed in the middle of the gauze leading to the bottom 
of the wound around which salt sacks as recommended by Col. Gray 
should be placed. The salt sacks should be carefully placed at some 
distance from the walls of the cavity. The wound should be next 
dressed in the customary way with sterile gauze and wool dressing. 
A wound dressed in this way requires no further drainage. The dis- 
charge will find exit through the loose gauze. The dressing should be 
removed at the end of twenty-four hours, the wound irrigated with 
saline solution and packed as before. At the end of four or five days 
the wound is dressed with gauze soaked in normal saline, or continuous 
irrigation as recommended in the Chapter on the General Treatment of 
Wounds, may be used. As previously stated the great advantage of 
this method of treatment lies in the fact that the patient may be trans- 
ported to a base hospital without being subjected to a process of re- 
dressing en route amid questionable environments. 

Treatment by Hypochlorous Acid. — This method of treatment of 
wounds is one of the evolutions in the wound treatment of the present 
war. It is extensively referred to in the Chapter on the General 
Treatment of Gunshot Wounds. The value of the treatment depends 
on the liberation of hypochlorous acid gas when the wound is treated 
with the powder eupad, which is made up of bleaching-powder and 
boric acid in equal parts as already referred to. Eusol is the other 
form of the hypochlorous preparation in use, but this is the liquid 
preparation and not so well adapted as the powder eupad for use in 
those cases about to undergo transport. The great value of the method 
depends on the power of the antiseptic; at the same time it is 
comparatively harmless in its effects upon the tissues. The wound 
should first be thoroughly cleansed in the manner already recom- 



372 GUNSHOT WOUNDS 

mended, then lightly packed with gauze in the meshes of which the 
powder has been dusted. Drains are put in place and the wound is 
then covered with gauze and bandage for transport. 

Immobilization of the Limb. — Fixation splints at field hospitals 
for cases about to undergo transport are limited in kind. In the ab- 
sence of adequate equipment the ingenuity and skill of the surgeon 
will often be tried to the limit. 

Plaster of Paris is of extreme value as an immobilizing splint in 
active campaign in cases which are free from suppuration. We used 
it very satisfactorily in the Spanish-American War. The British army 
Surgeons were very partial to its use in the Anglo-Boer War, and at 
the beginning of the present war it was largely used by the German 
surgeons. A plaster-of-Paris splint secures more accurate apposition 
of bone fragments, it has the advantage of providing absolute im- 
mobility of the limb, a great desideratum in transport, and it is 
easy to obtain. It may be applied to almost any variety of 
fracture. 

Unfortunately plaster possesses some serious objections and these 
have been specially noted in the present war. It is said that wide- 
spread infection in wounds causes the plaster to become foul, the wounds 
cannot be properly looked after in transport, and the application of the 
plaster requires too much time where many wounded have to be looked 
after by a limited personnel, as so often happens. Again, the rapid 
swelling which too often overtakes a limb attacked with septic 
anaerobes, renders a plaster splint dangerous. Wooden and metal 
splints are preferred where it is not considered advisable to use 
plaster. 

In the case of septic compound fractures, splints should possess 
the following requirements: (1) adequate extension of the limb which 
means so much in restricting pain during transport; (2) immobiliza- 
tion must be sufficient; (3) the splints should be made of a material 
like metal, that does not absorb discharge and which may be easily 
and readily cleaned; (4) they should afford easy access to facilitate 
dressing, and they should be capable of being slung so that dependent 
drainage may be carried out. A splint possessing these requirements 
will permit transport of a fractured limb easily in a motor car, or by rail. 

Treatment of Compound Fractures in Base Hospitals. — Treatment 
at a base hospital only means the management of compound fractures 
where surgeons have ample equipment and where they have entire con- 
trol of the environments. Such a station on the line of communica- 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 373 

tion is not reached ordinarily for several days. There has been ample 
time for the development of certain complications which will guide the 
surgeon in his treatment. There may or may not be a marked degree 
of infection. In the case of the latter, amputation may be called for, 
as for instance in fractures complicated by the presence of gangrene 
of a limb. Amputation may also be called for in cases of secondary 
hemorrhage, or in cases of gas bacillus infection in limbs having sus- 
tained extensive laceration of soft parts with or without profound 
toxemia. 

When amputation is not called for, or in anatomical regions where 
the question of amputation does not arise, the surgeon should treat 
the case by thorough exploration, free drainage, removal of necrotic 
tissue, foreign bodies, and loose fragments of bone. In septic cases 
with persistent oozing of blood, plugging should only be employed as a 
temporary measure — pending the time when one has the opportunity 
to freely lay the wound open and secure the bleeding vessel by forceps 
or ligature. 

In the more fortunate conditions, in which the presence of sepsis is 
not a marked feature, the wound should be dressed as already recom- 
mended and then immobilized. 

X-ray evidence should be sought at the earliest moment at the 
field or base hospital and the measures of treatment suggested thereby, 
such as removal of foreign bodies, loose fragments of bone, etc., should 
be instituted. Lodged balls, in bone, which are not causing injury by 
their presence, should be allowed to lie in the tissues until complete 
recovery, lest infection is provoked anew in attempts at removal. 
Divided nerve trunks in a septic wound should not be sutured until 
the wound has become aseptic and preferably after it has healed 
entirely. 

Among the operations that may be performed on compound frac- 
tures at base hospitals we may mention that of wiring or plating. A 
number of expert surgeons have undertaken this plan of treatment in 
the present war. 

The questionable practice of plating in compound comminuted 
gunshot fractures among war wounds is dealt with interestingly by 
Lake 1 in a recital of his nine months' experience at the front, in France. 
He did not see it used in any of the French military hospitals that he 
visited nor did he hear of its use in English hospitals. 

The importance of obtaining a good anatomical result in the pres- 

1 Plating of Gunshot Fractures by N. C. Lake, Brit. Med. J., 1915, II, 44. 



374 GUNSHOT WOUNDS 

ence of comminuted bone and the difficulties which the latter offers 
is fully appreciated by the author. The hindrance, from the presence 
of sepsis which is found in all cases, is also noted. Lake's wide ex- 
perience has taught him that fresh infection of soft parts is negligible 
in view of the already extensive damage, and that fresh infection of 
the bone does not occur to any extent worthy of consideration. In 
some of the smaller bones a previously septic wound has been found to 
heal completely over a plate, a fact which may be attributed to the 
healthy condition of the tissues prior to the injury. In most cases, 
however, the plates tend to loosen in the presence of sepsis, but not 
to the extent he was led to expect, and the loosening does not occur 
to an extent sufficient to affect the original object of the plates until the 
fragments have become partly fixed, say in, two or three weeks. The 
plates seem to have little effect on the septic process and some of the 
loose ones become consolidated again. For these reasons the author 
is of the opinion that objections to the use of internal splints are 
rather theoretical than otherwise. The ease with which the dressing 
can be manipulated, and massage and other treatments be applied to 
neighboring points and soft tissues as compared to a limb under treat- 
ment by external splints is specially noted. 

The amount of comminution necessitates the use of longer plates 
than those in ordinary use. In some shell wounds comminution is so 
extensive as to exclude the use of plates, and in these cases a divided 
plaster having a soft iron connecting piece bent to form a handle to 
manipulate the limb is found to be of value. 

The plating operation is not undertaken until acute sepsis has been 
subdued and radiographs have been taken — about four days after 
admission. The taking of radiographs in two planes, at right angles 
to estimate the amount of destruction and to better reconstruct the 
damage done, is considered very essential. No routine method is 
used to combat sepsis, each case being treated according to indica- 
tions. Either a dusting powder composed of benzoic acid 25 grams, 
salol 5 grams, quinine 25 grams, and magnesium carbonate 25 grams 
proved of use in very dirty cases after a preliminary cleaning under an 
anesthetic. To establish the lymph flow as recommended by Sir 
Almroth Wright hypertonic saline solutions with and without vaccines 
are used; but once the sepsis is limited, more reliance is placed on the 
application of a Bier's bandage or a suction cup when practicable. 
Sun-baths and injections of colloid gold, so highly recommended by 
French surgeons, have been used with doubtful results. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 375 

By the energetic use of the methods mentioned sepsis is consider- 
ably reduced after a few days, at which time plating can be done. In 
most of the war wounds an incision is unnecessary or the original 
wound needs to be only enlarged. The good exposure thus obtained 
is an advantage in point of drainage. The fragments are carefully 
replaced, which except those entirely detached must obviously die. 
While this preliminary arrangement is being made, surrounding struc- 
tures are carefully examined for injury. In a search of this kind, in 
two cases of plating of the humerus, the musculospiral nerve was 
found in such a position that it would later have been involved in 
callus. It was promptly freed and buried in muscle to prevent symp- 
toms of pressure later on. Many such cases involving tendons, 
vessels, and nerves were found and remedied in accordance with the 
indications offered. After exposing the ends of the main fragments 
the plates are put in place without disturbing the periosteum unduly. 
The most useful plate employed was one having two screw holes near 
together at the end, with one or two intermediate ones. The latter 
often hold intervening small fragments in good position. It is pref- 
erable not to put screws near fractured ends. Holes are carbolized 
before putting the screws in place. Fresh incisions may be closed, 
although they may be left open a few days to insure drainage, and 
closed by suture later. The limb is found quite rigid after plating and 
the subsequent management is devoted to keeping down sepsis for 
the next three or four weeks. The author states that the limb may be 
treated the same as one without fracture, as far as early movements 
and massage may be indicated. After one month the parts have be- 
come solid enough so that any plates that show a tendency to be loose 
may be removed except where there is a gap, and the plate is then 
retained as it may assist in preventing shortening. Several weeks 
later a sequestrum is found embedded in a cavity of bone or fibrous 
tissue, which should be removed. To close the remaining cavity bis- 
muth paste has given good results. Before this is resorted to, the 
cavity is swabbed with pure carbolic acid, and iodoform paste is 
used for a few days. Skin-grafting was often resorted to, to assist in 
rapid closure of wounds. 

Many cases remained ununited except by deposit of fibrous tis- 
sue between the bone-ends. For these bone-grafting is recommended 
later. 

The concluding paragraph should convince anyone that it will be 



376 GUNSHOT WOUNDS 

a long time, if ever, before plating becomes an adopted mode of treat- 
ment in gunshot fractures in military surgery. 

Even in simple fractures asepsis has always been the sine qua non 
to intervention. Bone tissue at best offers poor resistance against 
infection, and for that reason the propriety of plating bone in compound 
fractures has always been questionable. In gunshot fractures where 
so much comminution and laceration of tissue exists in the presence 
of heavy infection, and amid surroundings which often forbid the 
possibility of carrying out the rules of asepsis completely, as is found 
in the emergency conditions of field surgery, the practice of plating 
at best could only be undertaken by experts in selected cases. 

In military surgery it should also be remembered that the gaps 
which are apt to occur in the continuity of the long bones from shell 
fracture and the comminution common to bullets of high velocity, 
have hitherto been filled in a surprising way by new bone. In the few 
cases in which Nature fails to provide the bone, there is an oppor- 
tunity of replacing the intervening fibrous tissue with bone-grafts. 
In pseudo-arthrosis with loss of bone substance, bone-grafting offers 
absolutely safe and nearly perfect results. Lambotte states that 
personally he has never resorted to a mutilating operation for 
pseudo-arthrosis from loss of bone substance. He strongly advo- 
cates strict asepsis in the use of bone-grafting and emphasizes his 
belief that living bone will graft itself perfectly and continue to 
live in its natural state, and this is especially true of autoplastic 
grafts. 

Treatment of Gunshot Fractures of the Humerus. — Of eighty-seven 
gunshot fractures of the humerus reported by the Surgeon-General 1 
from the Spanish- American War and Philippine Insurrection 1898- 
1901 inclusive, there were five deaths or a mortality of 5.7 per cent. 
Twenty-one of the eighty-seven cases were due to bullets, kind not 
stated, thirty-two were caused by Spanish Mausers of reduced caliber, 
seven by Krag-Jorgensen bullets, four by revolver bullets, seventeen 
by Remington rifle bullets, one by shrapnel ball, one by piece of shell, 
two by pieces of steel and slugs. The disposition of the cases was as 
follows: Thirty-nine or 45 per cent, were restored to duty, twenty- 
nine discharged for disability and twelve were otherwise discharged the 
service. There were ten amputations performed, one resection, frag- 

1 Annual Reports, S. G., U. S. A., 1898-1902. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 377 

ments of bone were removed in several cases and incision for drainage 
was done in one case. There is no available record of the number of 
lodged balls. 

Hickson 1 in his report of cases in the South African War gives notes 
of eighty-three fractures of the humerus caused by every variety of 
projectiles. Forty-two of the eighty-three cases were septic. Re- 
moval of fragments was done in twenty-two cases in every one of which 
sepsis was present. There were thirteen amputations or an amputa- 
tion rate of 15.6 per cent, and sepsis was present in all of these. There 
were but three deaths out of the eighty-three cases, a mortality of 
3.6 per cent. 

The mortality for the two groups cited, those in the Spanish- 
American and Boer Wars, speaks well for the modern methods of wound 
treatment in war, and the beneficence which comes from the use of 
reduced-caliber rifle bullets. More than half of our cases were due 
to this bullet although the records ascribe many of the wounds due to 
" bullet" in the returns, a convenient term, employed by surgeons 
generally. For instance of the eighteen cases from the battle of 
Santiago, twelve are put down as due to bullets when as a matter of 
fact we know that they were nearly all due to injury by the Spanish 
Mauser. 

Conservative Treatment. — Conservation should be practised in 
all gunshot injuries of the humerus, except those in which the nec- 
essary blood and nerve supplies of the arm have been destroyed, 
regardless of the amount of comminution. In preantiseptic times sur- 
geons often sacrificed arms on account of extensive bone lesions which 
are perfectly amenable to treatment now. Under our present method 
of wound treatment, we look for consolidation of fragments, however 
numerous, provided they are attached to periosteum or soft tissues 
which give them blood supply. We look for consolidation even in 
cases where there is loss of bone substance in continuity for 1 or 2 
inches. Nature will fill the gap with callus in time. To insure all 
these expectations on the part of nature it is necessary first of all to 
exclude sepsis, and the fate of the limb will depend upon the surgeon's 
ability to maintain asepsis. To this end the skin and wound are to be 
cleansed thoroughly by scrubbing with soap and water, and by 
irrigation with antiseptic solutions. To facilitate exploration the exit 
wound, which is usually larger, and near which the bulk of fragmenta- 
tion is found, should be enlarged by incision when necessary. Frag- 

1 Op. cit. 



378 GUNSHOT WOUNDS 

ments which still adhere should be replaced as near as possible to their 
normal position, after they have been released 'from any entanglement 
with the soft parts, and those fragments which are entirely detached 
should be removed. In wounds showing explosive effects it is not 
unusual to find fragments buried in the tissues 2 and 3 inches from the 
point of fracture. The wound should be dressed antiseptically, a 
drain put in place to be retained twenty-four to forty-eight hours, 
and the limb immobilized, including both the shoulder- and elbow- 
joints with the fore-arm flexed at a right angle. Immobilization 
should be accomplished by the splints ordinarily used in surgical 
practice, but plaster of Paris as a fixed dressing should be given pref- 
erence whenever it can be conveniently employed. 

In the lesser degrees of fracture, and in aseptic cases especially, 
exploration with a view to removal of detached fragments will not be 
necessary. Beyond cleansing the skin near the wound, a clean dressing 
and fixation of the limb as above stated, there is but little to be done. 

Hickson states that the most noticeable feature among the after- 
effects of the eighty-three cases from the South African War was the 
frequency of nerve injuries, especially the musculo-spiral. The large 
nerves were seldom cut by the projectiles, the lesions were a result of 
direct pressure by callus or fibrous bands. 

Non-union in fractures of the humerus, which F. H. Hamilton and 
others of our great authors have so often noted in civil practice, is 
happily very infrequent in military practice. Of 2900 cases of gun- 
shot fracture of the humerus in our Civil War Otis records but six 
cases of pseudarthrosis and two of these were after simple fracture. 
Neudorfer 1 states that he has not met with a single case in all of his 
military practice as a result of shot fracture. Non-union in civil prac- 
tice has generally been attributed to the difficulty of properly immobi- 
lizing the broken fragments. Sedillot 2 ascribed the generally uniform 
union of fractures after gunshots to the extent and activity of the 
osteogenetic process. 

Excision in continuity was once advocated by military surgeons 
and during our Civil War it was practised more than any time 
before or since. In badly comminuted fractures the older surgeons 
indulged the hope that a formal excision would be attended with less 
danger than an attempt at conservation, but the faithful and costly 

1 Handbuch der Kriegschirurgie, 1872, B. II, S. 1179. 

2 Du Traitement hes Fractures des Membres par Armes de Guerre. Arch. Gen. 
de Med., Ser. VI, T. XVII, 49; 381. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 379 

attempts in our Civil War had the tendency to array the dictum of the 
profession against the practice, so that it is no longer advocated as an 
operative measure. Otis significantly calls attention to the fact that 
in the 696 cases of excision in continuity in our Civil War the aggre- 
gate mortality rate was 28.5 per cent. This mortality is 12 per cent, 
higher than that in a larger series of primary amputations in the upper 
third of the arm and nearly double that observed in 3005 cases treated 
by conservation. Among those who recovered after excision in con- 
tinuity, one-third had "no bony union" or "false joint"; a number 
suffered consecutive amputation of the arm; and more still suffered 
ultimate exarticulation or amputation with a mortality of nearly 50 
per cent. The remonstrance which Otis made to the operation was 
accepted by men like Ashhurst, Hamilton, and Gross in this country, 
and MacCormac in England. Under our present mode of treatment 
we practise conservation in all the cases where excision in continuity 
was practised in the time of our Civil War. If we exclude sepsis 
from the foyer of fracture, callus will form to fill whatever gap may 
arise from loss of bone substance. Cases with loss of much bone in 
continuity can now occur only from shell wounds and from hand 
weapons when discharged at short range, producing explosive effects. 
Experience has taught us that such a wound treated conservatively 
by cleaning the field and the wound, removing loose fragments, and 
immobilizing the limb, is attended with less mortality than excision 
in continuity or a formal attempt to fill the gap by evening up the 
irregularity of the fractured ends with a saw, and then bringing the 
fragments together with wire, etc. 

Primary amputation of the arm is only justified in hopeless de- 
struction of soft parts, including the large vessels and nerves of 
the arm. The great value of the upper extremity to the patient's 
struggle for existence causes a surgeon to weigh well the nature of the 
injury and the condition of the patient, before he resorts to amputa- 
tion. The loss of an upper extremity is of such moment to the patient 
that he is often willing to take a certain risk on his life before giving his 
consent. Aside from this objection to primary amputation the older 
surgeons were fully cognizant of the wonderful resources of nature to 
restore a badly comminuted arm to its former utility. Non-union was 
seldom noted, and many of the military surgeons like Guthrie and 
Longmore were loath to sacrifice an arm, in spite of extensive 
comminution, including injury to the brachial artery. 

These views on amputation were entertained by the majority of 



380 GUNSHOT WOUNDS 

the Confederate surgeons in our Civil War. 1 They were largely 
guided by the following advice from Longmore: " Unless the bone 
be extremely injured by a massive projectile, or longitudinal com- 
minution exist to a great extent, especially if it also involves a joint, 
or the state of the patient's health be very unfavorable, attempt should 
always be made to preserve the upper extremity after a gunshot wound." 
These views held by the majority of the world's surgeons were not 
shared by those of our army between 1861-65, during which period, 
out of 8245 gunshot fractures of the humerus unattended by primary 
injury of the shoulder- or elbow-joints, there were 3259 primary 
amputations of the arm in the continuity of the humerus with a 
mortality of 18.4 per cent. The record shows that the surgeons in 
the Union Army practised primary amputation in 39.5 per cent, of 
the 8245 gunshot fractures of the humerus. Considering the consensus 
of opinion against the practice before and since, the percentage is 
large, but Otis offers explanations that go far to exonerate the field 
surgeons of the charge of sacrificing limbs without cause. Certainly 
many of the primary amputations that were performed were absolutely 
necessary on account of extensive lacerations by cannon shot with 
injury to vessels and nerves. There still remained a very large number 
in which amputation was performed because of extensive comminution 
of the shaft by the projectiles of hand-weapons. Considering the 
dangers of sepsis which then prevailed, and the unfavorable environ- 
ments which precluded the adoption of proper conservative efforts, on 
account of the absence of adequate hospital facilities, and the absence 
of safe and suitable transportation, Otis states that the surgeons very 
properly adopted what John Bell called "an argument of necessity as 
well as of choice, and limbs that in happier circumstances might have 
been preserved had often, in a flying army or a dangerous campaign, 

to be cut off; it is less dreadful to-be dragged along with 

a neat amputated stump, than with a swollen and fractured limb, 
where the arteries are in constant danger from the splintered bones." 
The plan of amputating amid such surroundings sacrificed many limbs, 
but at the same time we must admit that it was attended with the 
saving of many lives. 

According to Chauvel and Nimier, Legouest, and Delorme, a 

1 Warren (E). An Epitome of Mil. Surgery, 1863, p. 372, and Chisolm (J J). 
A Manual of Mil. Surgery, 1863, p. 386, and also a Manual of Military Surgery 
prepared for the use of the Confederate States Army, by order of the Surgeon- 
General, C. S. A., Richmond, 1863. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 381 

comminuted fracture of the humerus complicated by injury to the 
brachial need not necessarily be a cause for amputation in all cases. 
For instance, when the brachial is severed sufficiently low to insure the 
supply of the superior profunda, a policy of expectancy can be followed, 
watching meantime for the first sign of the occurrence of gangrene; 
but Delorme would do an amputation when the artery is severed as 
stated, if the anastomotica magna is also wounded. In other words, 
these authors believe there is no indication for amputation as long as 
the location of the wound in the branchial is such that its collateral 
circulation is not endangered. 

In the confusion and pressure for time and trained assistants 
that prevail in field conditions, the attention which it is necessary to 
bestow on a gunshot fracture with injury to the brachial in accordance 
with the foregoing rules, it not justified. The point made by these 
authors should, however, be borne in mind as it may exceptionally 
find application under more favorable environments. 

Secondary amputation more often became necessary in preantisep- 
tic times on account of secondary hemorrhage, persistent infection in 
bones and soft parts, and for remote effects such as useless and painful 
limbs. Out of the 5456 amputations of the humerus for shot injury in 
our Civil War there were 411 secondary amputations with a mortality 
of 27.7 per cent. 

Secondary amputations will be far less often noted in future 
wars. The success which modern surgeons obtain in saving limbs 
will no doubt cause useless limbs to become one of the most frequent 
causes for secondary amputation. It certainly forms one of the 
frequent causes of amputation in Soldiers' Homes. 

Gunshot Fracture of the Forearm. — Gunshot wounds of the left 
forearm are more frequent, and they are attended with greater 
mortality than gunshot wounds of the right forearm (Chauvel et 
Nimier) . Without offering any reason for the latter, these authors make 
the further statement that gunshot wounds of the left leg are more 
frequent than those of the opposite side, and that they are also attended 
with greater mortality. From 10 to 15 per cent, of all fractures in war 
are noted as fractures of the bones of the forearm. The ulna and radius 
may be fractured together or independently. In shots disposed antero- 
posteriorly or vice versa but one bone is usually fractured, while shots 
directed obliquely or transversely are most apt to be attended by 
fracture of both bones. The amount of fracture may range from 
guttering and partial fracture to complete fracture. 



382 



GUNSHOT WOUNDS 



The bones of the forearm, except at their epiphyseal ends, are hard 
and brittle, furthermore the compact substance is thin, all of which ac- 
counts for the limited foyer of fracture and Assuring usually observed in 
these bones. The area of fracture may be extensive at times as observed 






Fig. 141. Fig. 142. 

Fig. 141. — Fracture showing comminution with detached fragments involving radius and ulna 
by bullet from .45 cal. Colt's new service revolver at 75 yards, in cadaver. Bullet and metallic frag- 
ments from it are lodged. Army Med. School collection. Gibbs X-ray Laboratory. 

Fig. 142. — Fracture with detached fragments from .30 cal. Krag-Jorgensen bullet as a re- 
sult of slight grooving on internal border of bone. From Philippine Insurrection. Army Medical 
School collection. 



in fractures involving the two bones. In such cases, the first bone hit 
fragments, and its spicula, acting as secondary missiles, make an im- 
pact with the projectile on the second bone causing more than the usual 
amount of bone comminution and injury to soft parts (Figs. 141, 142 and 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 383 

143). The explosive type of fracture is especially common in the ulna 
as a result of its subcutaneous position, and for a like reason the same 
explosive type is more commonly exhibited in the lower third of the fore- 
arm, when fracture of one or both bones occurs. On account of the 
proximity of the arterial vessels to bone, injury to blood-vessels and 




Anteroposterior. Lateral. 

Fig. 143. — Radiogram showing two views in case of Pvt. Dennis M., late pvt. Co. "G," 9th 
U. S. Inf., wounded at Tiensin, China, during Boxer Rebellion, July 13, 1900, by large caliber lead 
bullet at 150 yards. Skiagram taken Feb. 1901. Remote effects: paralysis of wrist and hand with 
pain in forearm and elbow. Very slight movement in extensor tendons of fingers. Marked impair- 
ment of hand and fingers in the distribution of radial and median nerves. Army Medical School 
collection. 



hemorrhage, are among the frequent complications of gunshot fracture 
in the forearm. Injury to the interosseous arteries is especially 
common. 

From the statistics of the Spanish-American and Boer Wars we 
find as follows: Of 114 cases of gunshot fractures of the forearm 



384 GUNSHOT WOUNDS 

reported by the Surgeon-General, U. S. Army, for the years 1898-1902, 1 
thirty-six were caused by reduced-caliber bullets, mostly Spanish 
Mausers, sixteen by Remington bullets, forty by bullets, six by revolver 
bullets, two by slugs, two by shell, two by cannon, three by explosion 
of powder, one by shrapnel, one by explosion of a cartridge. The 
large majority of these fractures appear to have resulted from the 
projectiles of hand weapons. Ten of the cases or 8.8 per cent, suffered 
amputation, with one death — the only death recorded. Bone frag- 
ments were removed in ten cases, resection was done in one case, and 
lodged balls were removed in five cases. Fifty-six of the cases or 
49.1 per cent, were restored to duty, forty-four were discharged for 
disability, while the remainder were mustered out, discharged by 
order, etc. 

Of sixty cases of gunshot fractures of the forearm reported by 
Hickson 2 from the Anglo-Boer War, none terminated fatally. The 
radius was involved in twenty-seven cases, the ulna in eighteen, and 
both radius and ulna in fifteen cases. Of fifteen cases exhibiting 
fracture of both bones twelve were septic. Amputation was resorted 
to in three cases. 

Of the twenty-seven cases of fracture of the radius alone, sixty 
per cent, were septic, there was one amputation for gangrene from 
injury to the brachial at its bifurcation. Fragments of bone were 
removed in about 40 per cent, of the cases. 

Of eighteen cases of fracture of the ulna, all but two were septic. 
Amputation was necessary in two cases, one as a result of gangrene, 
the other as a result of extreme injury to bone and soft parts. 

Treatment. — With our modern methods of treatment conserva- 
tion, with very few exceptions, is the rule of treatment in all gunshot 
fractures of the forearm. A limb is never condemned to amputation 
except in cases of extreme traumatism of the soft parts, bones, and 
laceration of nearly all the principal arteries. During our Civil War 
out of 5194 gunshot fractures of the forearm, the precise seat of injury 
was specified in 4334 cases, and of this number the ulna and radius 
were fractured in 1291 cases. There were 1007 primary ampu- 
tations with a mortality of 9.5 per cent, and the majority of these 
were for gunshot fracture of both bones. Excluding one hundred 
and forty-three amputations practised for extreme traumatism as a 
result of injury by cannon balls, shells, or fragments from torpedoes, 

x Annual Reports of the Surgeon-General, U. S. Army, for 1899-1903. 
2 Op. cit. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 385 

we have a total of 854 instances of amputations which were done on 
account of lesions arising from the projectiles of hand weapons. There 
were also nearly 1000 excisions done for injury to the bones of the 
forearm, " of which a very small proportion were attended by absolute 
destruction of the parts by large projectile or explosions, or by injuries 
of all the principal blood-vessels or nerves." This large proportion 
of amputations and excisions was subsequently condemned by Otis 
as unnecessary, the excisions added to the mortality and seldom im- 
proved the utility of the limb among those who survived. This 
mania for operative work is ascribed by Otis to the number of " inex- 
perienced medical officers, hastily summoned to the field in emer- 
gencies." Otis shows that the greater number of operations were 
performed during the earlier part of the war and that mature judgment 
and experience condemned the practice later. Amputation, except for 
the reasons already mentioned, was frowned upon by all of the noted 
authorities at that time, and with our present methods of wound treat- 
ment conservation finds additional emphasis. Conservation should 
always be practised in gunshot fracture of one bone, although com- 
plicated by wound of one or the other of the larger arteries. Delorme 
even advocates conservation in cases where both arteries — the ulnar 
and radial — are involved, provided the interosseous arteries are not 
injured. The rule is never to resort to amputation except in those 
cases where both bones are fractured and the large arteries are severed, 
or when extensive traumatism of the bone and soft parts occurs from 
shell fragments, implicating also the median and ulnar nerves. 

When conservation is decided upon, bleeding vessels should be 
tied, severed tendons and nerves should be sutured, and all detached 
fragments removed. The wound should then be irrigated with an 
antiseptic solution, drainage provided for and the limb immobilized. 
The latter can be accomplished by straight forearm splints or pref- 
erably plaster of Paris. Massage of the fingers, wrist and elbow 
should be practised early during convalescence to preserve the utility 
of the arm and hand. 

Excision in the continuity of the bones of the forearm for gunshot 
was never considered a favorite operation in military surgery. Of 
965 cases of excision at all clinical stages in our Civil War the mor- 
tality was 11.2 per cent., while in 2943 cases treated by expectation 
it was but 6.4 per cent. In addition to the objection on the score of 
mortality, Otis states that he was unable to find a single instance 
with a satisfactory result, concerning the utility of the limb. 

25 



386 GUNSHOT WOUNDS 

The operation has found no adherents in recent times. Con- 
servation, removal of detached fragments, and rigid antisepsis render 
excision at any time entirely unnecessary. 

Amputation. — We sacrifice the limb in gunshot of the forearm 
when both bones are fractured, and the larger arteries are severed, or 
when extensive traumatism of the bones and soft parts occurs from shell 
fragments implicating the median and ulnar nerves. Ten amputations 
of the forearm for gunshot fracture are reported from the Spanish- 
American War with one death. Five cases suffered amputation in the 
Anglo-Boer War with no death. 

Gunshot Wounds of the Hand. — Out of 105,786 shot wounds 
during the last year of our Civil War Otis found that 5.3 per cent, were 
of the metacarpus and 4.9 per cent, were of the phalanges or fingers. 
Out of a total of 11,369 gunshot wounds of the hand during the 
whole of the same war there was an aggregate mortality of only 
3.1 per cent. The modern notion that gunshot injury of the 
hand is prone to the development of tetanus is rather negatived by 
Otis' statistics, since only twenty-four cases supervened out of the 
large series referred to. The occurrence of tetanus from gunshot 
of this region has received special attention by the surgeons of this 
country in connection with toy-pistol injuries to which we have 
already referred. 

The character of the lesion in the metacarpal bones by the modern 
rifle bullet consists of comminution to a greater or less extent with an 
occasional example of grooving or perforation. Transverse shots 
across the metacarpal bones of the hand, and also shots similarly 
disposed across the metatarsal bones of the foot, are prone to show 
particles of lodged metal on X-ray plates. This fact has been com- 
mented upon by experimenters and by surgeons who have described 
the characteristic features of gunshot wounds in recent campaigns. 
It has seemed strange that a resistant projectile, armored with a 
steel jacket that usually withstands the hardness of the long bones 
like the femur and tibia, should disintegrate on impact against a 
number of small thin brittle bones, like those of the metacarpal in the 
hand. The reason for this seems to lie in the fact that the bullet is 
deflected for the want of proper support after passing through the 
first or second bone and that, as it commences to make an irregular 
impact, when still possessed with sufficient momentum, the pressure 
which is exerted on the sides of the bullet causes its nucleus to separate 
more or less from the j acket with a tendency to disintegration of the whole 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 387 

bullet, hence the pieces of metal that remain lodged. Ordnance 
officers have seen the same thing occur in projectiles when fired 
against certain thicknesses of armor plate placed one behind the other, 
and disposed at short intervals. Projectiles that find proper support 
while penetrating a target of solid metal hold their original shape, but 




Fig. 144. — Radiogram in case of James M. Derm, 95th Regiment Penn. Vols, shows lodged 
Minie ball in palm right hand since the battle of Spottsylvania, May 10, 1864. Ball entered dorsum 
2 cm. behind metacarpo-phalangeal joint opposite point of lodgment. Ball lies imbedded in a 
cyst which has developed from the synovial sheath of the flexor tendon of the thumb. Ball removed 
by the author at the U. S. Soldiers Home, June 26, 1902. Missile was loose in a thick sac under 
palmar fascia. Sac contained about 1 ounce of hemorrhagic fluid, the blood being no doubt the 
result of frequent traumatisms from shaking the hand violently near the ears of his friends to cause 
them to hear the ball rattle in the cyst. The succussion sound made by the loose ball and the 
fluid in the unyielding sac was very perceptible to the sense of hearing. Radiogram was taken 
June 26, "1902, 38 years after the injury. U. S. Soldier's Home Hospital Laboratory, Dr. A. B. 
Herrick, X-rayist. 



they generally break up when fired against a target composed of a 
number of plates as above described. 

The mortality from gunshots of the hand under modern conditions 
is very small. Out of 470 cases reported by the Surgeon-General, 
U. S. Army, for the years 1898-1902, l there were five deaths. One 

1 Annual Reports S. G., U. S. A., for 1899-1903. 



388 



GUNSHOT WOUNDS 



of these was due to tetanus, one to septicemia, one from gangrene 
which necessitated amputation at the shoulder, and the other two were 
due to causes not related to the injury. Wounds of the hand are 
generally septic. Of thirty cases noted by Hickson in the Boer War 
twenty-six or 86.6 per cent, were infected. 

Treatment. — The most rigid antisepsis should be used from the 
beginning. The application of a first-aid dressing alone should 
not be considered sufficient in gunshots of the hand. The whole hand 




Fig. 145. — Radiogram in case of Pvt. A. Cor- Reg — U. S. Army. Shot with .32 Winchester rifle 
at Ft. Custer, Mont., 1882. (1) Bullet and a fragment lodged near greater trochanter. (2) Sup- 
purating sinuses marked by bismuth injections. Bullet removed by Col. Crosby, Med. Corps, 
U. S. A., at Soldiers Home, Sept. 1911. Army Medical School collection. 

should be painted with tincture of iodine or thoroughly scrubbed 
with soap and water and the wound thoroughly irrigated with bichlo- 
ride of mercury 1-2000. Detached spicula of bone should be re- 
moved, drainage provided for, and after the application of a clean 
dressing the hand and forearm up to the elbow should be immo- 
bilized. If sepsis sets in, the continuous arm bath will be of great 
service; and if suppuration is impending free incisions and thorough 
drainage should be practised early. In extensive comminution of 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 389 

the phalanges and metacarpal bones the surgeon should make every 
effort to preserve as much of the injured part as may be consistent 
with even a partial degree of utility. The advantage of preserving 
one or more fingers, as, for instance, the thumb and one finger or the 
index finger alone, is of great value. 

Gunshot Injuries of the Shaft of the Femur. — There were 6738 
shot injuries of the femur in our Civil War, of which 162 were classed 
as contusions and 6576 as gunshot fractures. 




Fig. 146. — A recent skiagram showing lodged conoidal bullet against bone in old soldier wounded 
in Civil War, 1861-65. Reported by Lt.-Col. George DeShon, Med. Corps, U. S. Army. Army 
and Navy Genl. Hospital, Hot Springs, Ark. X-ray Laboratory. 



Shot Contusion of the Shaft of the Femur. — The contusions of 
the femur from gunshots were more frequent than those of the humerus 
already referred to. Otis records that amputation became necessary 
in nine instances with seven fatal results, a mortality of 77.7 per cent., 
while the remainder 153 were treated conservatively without operation 
with a mortality of 22.8 per cent. (Figs. 145 and 146). 

There is no reference to contusion from gunshots of bone in recent 
wars. The lesion is evidently more rare with the new armament, or 
the present method of wound treatment, which tends to keep wounds 



390 GUNSHOT WOUNDS 

aseptic, does away with the inflammator}^ complications that formerly 
masked the lesion. Still we might naturally expect a larger per- 
centage of gunshot contusions with the use of the old, larger-caliber 
lead bullets, than from the highly penetrating rifle bullets of the present 
day, which seldom lodge. 

Gunshot Fractures of the Shaft of the Femur. — Shot fractures 
of the femur occurred in 26.9 per cent, of all gunshot fractures, and 
they formed 2.3 per cent, of all wounds in our Civil War hospitals. 
The mortality in 6576 recorded cases was as follows: for the upper 
third 49.7 per cent.; middle third 46.1 per cent.; the lower third 
42.8 per cent. 

The foregoing statistics agree in the main with the results following 
similar injuries in the wars before the introduction of antisepsis and the 
change in armament. 

In recent wars we have gathered enough data to show a marked 
change for the better in the outcome of gunshot fractures of the femur. 
There were 132 cases of gunshot fracture of the femur in the Spanish 
American 1 War with a death rate of 14.3 per cent.; and 170 cases were 
recorded for the Boer War 2 with a mortality of 17 per cent. Of the 
132 cases from the Spanish-American War the projectiles of the hand 
weapons were responsible for 97 per cent, of the fractures, and at 
least 75 per cent, of these were the result of shots from the reduced- 
caliber rifles. Shell and shrapnel only caused two fractures each. 
The greater mortality in the British returns from the Anglo-Boer War 
was doubtless due to the greater number of severe fractures from 
artillery fire. Hickson states that "a considerable number were 

due to shell wounds including the Vickers-Maxim." 

Otherwise the cases from the two wars were quite similar. They 
were inflicted in battle for the most part, and they received the same 
treatment and about the same care and attention. If we group the 
cases of the two wars together we have 302 cases of gunshot fracture 
of the femur which under modern conditions give a mortality of 15.8 
per cent. By deducting this percentage from 46.2 per cent., which 
was the mortality of gunshots of the femur in the Civil War, we find 
the gratifying reduction of 30.4 per cent, in the mortality of gunshot 
fractures of the thigh under modern conditions as compared to the 
mortality in preantiseptic times. 

Treatment by Conservation. — Under modern conditions the 

1 Annual Report S. G., U. S. A., 1899-1902. 
2 Lt.-Col. S. Hickson, op. cit. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 391 

large majority of gunshot fractures of the femur are treated by con- 
servation. This mode of treatment is applicable in all cases except 
those attended by extensive comminution, laceration of soft parts, 
and destruction of the main vessels and nerves. 

Until 1848, the treatment followed by military surgeons in fractures 



Fig. 147. — Figs. 147, 148 and 149 show the happy results in a gun-shot fracture treated by 
modern conservative methods. 

Pvt. Harvey B., 27th Co. U. S. Coast Artillery was shot at 100 yards range by the U. S. Army 
pointed, Springfield rifle, full-jacketed bullet. A clean dressing and immobilization were em- 
ployed at once. No infection ensued. Slight displacement of fragments, with 1 inch shortening. 
Limb is strong and serviceable. A slight limp renders patient unfit for military service. Dis- 
charged on S. C. D., at U. S. A. Letterman General Hospital, Nov. 13, 1911. Fig. 147 shows femur 
immediately after injury. Figs. 148 and 149 give postero-anterior and side views of femur with 1 
inch shortening at time of discharge. Reported by Major R. M. Thornburg, M. C, U. S. A., from 
Letterman General Hospital. 

of the femur was amputation in all cases. Doubtless the rule was 
established after mature experience in earlier times. It was the com- 
monly accepted belief among surgeons then that all gunshot fractures 
of the femur ended fatally unless they were treated by amputation. 



392 



GUNSHOT WOUNDS 



The ever-present factor relating to sepsis and its complications, as 
well as the gravity of the lesions incident to the use of the armament 
of those days, no doubt played a great part in the toll of deaths, and 
in the reason for the establishment of the radical treatment by amputa- 
tion. However this may be, in 1848 it was pointed out by the surgeons 
of the French school, notably by Malgaigne, Velpeau and Jobert, 
that treatment by conservation had become preferable to treatment 





Fig. 148. 



Fig. 149. 



by amputation. Of 4000 inmates in the Hotel des Invalides, Paris, 1 
1814-21, there were but seven who had recovered after conservation for 
gunshots of the femur, while from 1847 to 1853 there were sixty-three 
inmates who had been cured after conservation, and during the 
same period but twenty-one who had suffered amputation for gunshots 
of the femur. Since then the plan of treatment by conservation has 
steadily gained in popular favor. Our Civil War affords statistics of 
the greatest value upon the results which just preceded the antiseptic 
era. Out of 6576 gunshot fractures 3467 were treated by conserva- 
tion. For the latter the mortality for fractures of the upper third 
1 Delorme, Op. cit. 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 393 

was 46 per cent.; the middle third 40 per cent.; the lower third 38.2 
per cent., while the mortality following amputation was for the upper 
third 73.6 per cent.; for the middle third 53.3 per cent, and for the 
lower third 45 per cent. 

The conservative treatment of gunshot fracture of the femur at 
the present time is very much the same as that already referred to in 
the case of the other long bones. Rigid antisepsis must be practised 
in all the details attending exploration. The latter is generally done 
by enlarging the wound of exit. All loose fragments as determined 
by digital examination should be extracted, and those which still 
adhere to periosteum or soft parts should be replaced as near as possible 
to their normal position. After bleeding has been properly checked 
the wound should be irrigated with a weak antiseptic solution, proper 
drainage should be employed for the next twenty-four to forty-eight 
hours, and the limb should then be dressed with a clean dressing and 
immobilized. The latter is most effective when it includes the pelvis, 
hip and foot. When transport is inevitable immediately after the 
injury, nothing takes the place of a well fitting plaster-of-Paris cast 
with window space opposite the wounds. This has some objections, 
however. The cast needs watchful care lest the bandage should 
constrict and cause unnecessary suffering. In the absence of plaster 
of Paris, splints of wire netting or a Hodgen splint which tends to 
obviate undue displacement of the upper and lower fragments is very 
popular with military surgeons. Sand bags and a long outside with a 
short inside splint and a Buck's extension will answer in the absence 
of something better. The great problem is to keep the limb immobile 
and to avoid sepsis. The first is met most effectually with a plaster 
cast, and the latter will require the unremitting attention of the surgeon. 
In spite of their well directed efforts the British surgeons noted 101 
septic cases out of 170 gunshots of the femur in South Africa. Out of 
twenty-nine deaths, twenty-six or 89.6 per cent, died of sepsis. 

Excision. — Excision of the femur for gunshot fracture never was 
a popular method of treatment and, like excision of the humerus, it 
is no longer advocated by military surgeons. It proved to be a very 
fatal procedure in our Civil War. Otis records 175 excisions of the 
femur for gunshot fracture. Ninety-one of these were done in the 
primary stage with a mortality of 76.4 per cent. Thirty-eight cases 
in the intermediate stage with a mortality of 81.2 per cent.; and eight- 
een in the secondary stage with a mortality of 16.6 per cent. All 
the cases for which primary excisions were once resorted to are now 



394 GUNSHOT WOUNDS 

amenable to treatment by conservation. The only possible excuse 
for exsecting part of a fragment now is found in cases where the jagged 
end of a bone is uncovered by periosteum. This should be rounded off 
with a rongeur, otherwise the fragments which still adhere should be 
replaced, as already recommended, as far as possible to their normal 
position, and the case treated conservatively. 

Amputation. — At the same time that conservation is the rule of 
treatment for gunshot fracture under modern conditions, there are cases 
in which primary amputation is the only measure to be resorted to. 
It is absolutely indicated (1) when a limb has been entirely or partly 
torn away by a large projectile or shell fragment; (2) in comminuted 
fracture with great destruction of soft parts common to wounds from 
large shell fragments; or (3) in comminuted fractures attended with de- 
struction of the femoral vessels should the patient live long enough to 
reach hospital care, and again (4) in comminuted fractures with destruc- 
tion of soft parts complicated by destruction of the great sciatic nerve 
high up, all require amputation. In cases where there is doubt, the 
environments often decide in favor of amputation to the exclusion of 
conservation. The crowded condition of the field hospitals, and the 
lack of a sufficient force of trained assistants to properly safeguard the 
wounded against infection are conditions that are apt to compel ampu- 
tation in military practice at times. Enforced transport is harmful to 
all kinds of fractures, it is prone to bring on or to aggravate existing 
infection and this is especially true of gunshots of the femur. When- 
ever possible these fractures should not be moved for a month or six 
weeks. 

When the thigh is torn away by a large shell fragment, bleeding 
vessels should be tied, the skin and soft parts should be disinfected and 
dressed antiseptically pending the disappearance of shock, which is 
generally present in all such cases. When reaction has set in, part of 
the femur should be removed through a longitudinal incision on the 
outside of the thigh and the soft parts trimmed and cleansed, the 
vessels should be tied, and the end of the bone properly covered. 
This tentative method of dealing with cases when the thigh is torn 
away becomes more imperative as the site of the injury nears the upper 
end of the femur. If a better stump is desired later, it can be obtained 
by performing a new amputation. 

We had 132 gunshot fractures of the femur in the Spanish-American 
War and the British Armv in South Africa had 170 cases. If we place 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 395 

the two groups together for comparison as to death rate after amputa- 
tion we find the following: 

AMPUTATION OF THIGH FOR GUNSHOTS IN THE SPANISH- 
AMERICAN AND BOER WARS 



Position 


No. cases 


Died 


Death rate 


Upper third 

Middle third 
Lower third 


27 
21 
11 


14 
9 
3 


51.8 
46.6 
27.2 


Totals 


59 


26 


42.5 



Besides the cases given in the foregoing table the British had 
thirteen amputations at the hip for gunshot fracture of the femur with 
eight deaths, a mortality of 61.5 per cent, and six amputations of the 
thigh, the point of amputation "not specified," with three deaths, a 
mortality of 50 per cent. If we add these to the foregoing table we 
have a total of seventy-eight amputations for gunshot of the femur with 
thirty-seven deaths or a mortality of 47.4 per cent. There was a 
considerable number of fractures due to shell wounds in South 
Africa and but two cases in the Spanish- American War, so that by 
grouping the cases from the two wars, we have the results as far as 
the character of the lesions is concerned nearer the condition which 
must obtain in the wars of the present. 

The mortality after amputation of the thigh for gunshot fracture 
in the wars of to-day is higher than one would expect from the favor- 
able results that attend other operative procedures under modern 
conditions. The mortality in the preantiseptic era was always very 
high. In the Crimean War out of 1666 amputations of the thigh there 
were 1532 deaths, a mortality of 91 per cent.; in our Civil War out of 
6229 amputations of the femur, of which 2900 were performed for 
gunshots of the femur proper, there were 3310 deaths or a mortality 
of 53.8 per cent.; and of 9017 amputations of the thigh as a result of 
gunshot collected by Otis in the important wars, between 1689 and 
1876, there were 7049 deaths, a mortality rate of 83.2 per cent. It is 
safe to state that the vast majority of fatal cases in the preantiseptic 
era died as a result of sepsis. The curse of the latter which pursued 
the older surgeons seems still to cling to the practice of military 
surgery. Thus Hickson states that of the 170 cases of fracture of the 



396 GUNSHOT WOUNDS 

femur in the Anglo-Boer War amputation was resorted to in forty-five 
cases with a death rate of 53.3 per cent., and that the indication for 
amputation was septic infection in all of the cases except three, which 
required amputation as a result of severe primary hemorrhage. Of 
the thirty-one amputations of the thigh in our records for the Spanish- 
American War the indication for operation as far as we are able to 
learn was septic infection in the large majority. These facts are 
touched upon, not with a view to criticize adversely the practice of 
the field surgeons, but to lay renewed stress upon the necessity for the 
exercise of the greatest care in the management of gunshots of the 
femur from the time of the first dressing. In cases which exhibit 
doubt as to the necessity for exploration, the decision should always 
be in favor of operation. Enlarging the wound of exit, removal of 
loose fragments, thorough irrigation of the foyer of fracture with a 
weak antiseptic solution and the establishment of good drainage, will 
keep sepsis in abeyance and check it ultimately, and when this is 
done the principal reason for amputation with its high mortality will 
have been set aside. 

Gunshot Fractures of the Leg. — There were 9171 injuries of the 
bones of the leg in our Civil War, of which 183 are ascribed to shot 
contusions, while the remainder were shot fractures. The statistics 
of our war hospitals at that time show that about one-third of the 
fractures of the long bones are found in the leg, and that they form 
about 3 per cent, of war wounds by gunshot. 

The tibia and fibula are harder than the long bones generally, 
and on account of their exposed position in the lower part of the leg 
the fractures in this location exhibit a high degree of comminution, 
amounting to explosive effects in a considerable proportion of the cases. 
The latter, though not specially dangerous to life, call for a large per- 
centage of amputations. 

Contusion of the bones of the leg was more frequent with the use of 
the lead bullets of the old armament. They are so far but seldom 
referred to in the wars of the present. Still, the exposed position of the 
tibia and fibula will render them liable to this form of lesion. Otis 
found that the internal surface of the tibia is more liable to this accident 
than the other surfaces of the bone. Out of 175 contusions treated by 
conservation he found the lesion located on the internal surface in 132. 
Contusion of the fibula is less serious than that of the tibia. 

Treatment of Contusion. — The rule of treatment is the same as 
that laid down for contusion of bone from gunshot already referred 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 397 

to, and this consists largely in employing means to prevent sepsis. 
Projectiles lodged adjacent to bone should be removed as soon as 
located, and the limb should be immobilized from the beginning. 
With the first evidence of inflammatory disturbance in the bone 
implicated, free incisions should be made down to, and including the 
periosteum, and when the history of the case calls for it, the compact 
substance of the bone should be trephined down to the medullary 
canal, and this mode of drainage should be repeated in the continuity 
of the bone at such points as may be deemed necessary. Good drainage 
and thorough irrigation with antiseptic solutions will usually arrest 
the bone lesion, and when they fail amputation is called for. Otis 
refers to 183 cases of gunshot contusions of the bones of the leg in our 
Civil War, of which 165 were treated by conservation with fifteen 
deaths; eight were amputated in the leg with four deaths; one amputa- 
tion was done through the knee-joint with fatal result and nine suffered 
amputation in the thigh with six deaths. We have detailed the 
results in these cases of contusion to call special attention to the 
dangerous nature of such lesions. We have reason to believe that 
under our modern methods of wound treatment the sacrifice of life 
and limb mentioned can now be materially lessened. 

Treatment of Gunshot Fractures of the Tibia and Fibula. — The 
treatment of gunshots of the diaphyses of the bones of the leg will be 
dealt with under (1) treatment by conservation, (2) excision, (3) 
primary amputation and (4) secondary amputation. 

(1) Treatment by Conservation. — Out of 146 gunshot fractures of 
the bones of the leg treated by conservation in the Spanish-American 
War we had six deaths or a mortality of 4.1 per cent., while the 
mortality after amputation in fifteen cases was 13.3 per cent. 

The British returns from the South African War give account 
of 137 cases as follows: Fracture of the tibia and fibula, 48; fracture 
of the tibia alone, 72; fracture of the fibula alone, 17. The great 
difficulty in treating gunshot fracture of the leg is the almost uniform 
presence of infection. The British returns which contain accurate 
records on this point show that thirty-eight cases out of forty-eight 
fractures of the tibia and fibula together were septic. Although the 
number of septic cases is not available in our records, we have reason 
to believe that the percentage of septic cases was high. The shoes, 
boots, leggings and clothing surrounding the legs of soldiers in campaign 
are necessarily soiled unduly with dirt from the surface of the earth, 
and a gunshot through the leather and fabrics mentioned contaminates 



398 GUNSHOT WOUNDS 

the wound with septic microbes which find lodgment on shreds of 
clothing, pieces of leather, particles of skin, etc., which are carried into 
the wound by the bullet. Wounds in war do not receive the prompt 
attention that is generally bestowed upon them in fixed hospitals. 
Men lie where they are shot for a long time unattended. In a great 
battle, it may be days before all the wounds are properly dressed. Delay 
in gunshot fractures, where infection is unavoidable as it is in wounds 
of the leg, means a rapid spread of the infection, and unless medi- 
cal officers have the time and opportunity to grant the unremitting 
care and attention necessary to control the inflammatory conditions 
that already exist, there will be troublesome complications to combat 
later. A clean dressing and immobilization are the first indications 
in gunshot fractures of the leg. This is about all that can be done at a 
first-aid station. The dearth of water that generally obtains on the 
line has made this class of injuries hitherto difficult to deal with. We 
used to apply a clean dressing to a dirty field and trust the case to 
nature until a more favorable opportunity. Now we have in tincture 
of iodine or one of the iodine preparations already mentioned 
a valuable method of sterilizing the surface surrounding the wound, so 
that any additional infection from this source is preventable. At the 
earliest opportunity, those cases which require exploration should 
receive prompt attention. The wound of exit should be enlarged, 
and all loose fragments should be removed. Bleeding vessels should 
be tied, and when either the anterior or posterior tibial arteries are 
wounded the condition of its corresponding tibial nerve should be 
investigated, and when cut or lacerated it should be sutured. The 
bone splinters that remain attached to periosteum or soft parts should 
be put back in their normal position or as nearly so as possible; 
drainage should be employed; the wounds thoroughly irrigated with 
a weak antiseptic solution, dressed in the usual manner and the limb 
immobilized. A box splint or any of the methods generally used will 
answer at first; and later, nothing is better than a plaster-of-Paris 
splint. When the seat of fracture is near the knee-joint, the immo- 
bilizing apparatus should invariably include the latter. 

The following case exhibits the excellent results attainable under 
modern conditions: Captain James H. McC, 1st U. S. Vol. Cavalry 
(Rough Riders), was shot at the battle of Guasimas during the 
advance on Santiago, June 25, by a Spanish Mauser bullet. The 
bullet entered posteriorly and to the tibial side of the left leg 5 1/2 
inches above the internal malleolus. It smashed the tibia at this 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 399 



point badly and fractured the fibula. There were three small wounds 
of exit on the anterior surface of the leg just below the level of the 
wound of entrance. The wound was at once dressed with a field 
dressing. At noon the next day the writer assisted in operating upon 
the case on the hospital ship Olivette. While the patient was under 
ether we found the area of fracture in the tibia marked by the presence 
of a number of small pieces of loose bone near the wounds of 





Fig. 150. — Radiograms showing postero-anterior and side views in the case of 

Captain James H. McC. 

exit. The Mauser bullet had separated from its jacket and a number 
of pieces of the core and envelope were also removed. The wound 
was thoroughly irrigated with a 1-2000 bichloride of mercury solution 
and then immobilized. In March, 1913 — nearly fifteen years after 
the occurrence — the writer was able to secure a skiagram of Captain 
McC.'s leg. There is no deformity in the fibula, and but little de- 
formity in the tibia. Particles of lead from the core of the bullet are 
still embedded in the tissues. There is 3/4-inch shortening and some 
limitation of motion in the ankle as a result of injury to the ten do 
Achillis (Fig. 150). 



400 GUNSHOT WOUNDS 

Without the prompt and radical treatment that was practised in 
this case, there would have been long-continued inflammation of the 
surrounding tissues, and all the bone lesions that are common to such 
injuries. 





Fig. 151. Fig. 152. 

Fig. 151. — Photograph in case of Pvt. D. C. S., Co. "E," 20th Mass. Lower halves bones leg 
six months after injury. Tibia fractured by musket ball. Suppuration continued till amputation 
of limb six months later. Civil War specimen. No. 861 A. M. M. 

Fig. 152. — Photograph in case of W. A., Pvt. Co. "L," 8th U.S. Inf. Gun-shot fracture re- 
ceived in action in Philippines, Dec, 1906. Nature of weapon unknown. Amputation Oct., 1908. 
Photograph represents femur after amputation, it shows the later bone lesions that result from 
failure to promptly remove loose fragments from a comminuted fracture, a common condition in 
Civil War days. Army Med. School collection. From X-ray Laboratory, Letterman Genl. 
Hospital. 

We have selected two specimens from the Army Medical Museum 
to illustrate the ulterior effects of the old-time practice in bone lesions 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 401 



of gunshot wounds when expectancy and conservation were restricted 
largely to the efforts of nature (Figs. 151, 152 and 153). 

(2) Excision of the bones of the leg in their continuity is not a 
safe surgical precedure. It is sometimes done in a case showing great 
loss of substance in the tibia by resecting the fibula to correspond to 
the length of the injured tibia. In 
such a case the ends of the bones 
are to be wired. The success of 
such an operation depends on rigid 
sepsis, a condition that can seldom 
be assured in field practice. 

(3) Primary amputation of the 
leg is only practised now for extreme 
destruction of the soft parts with 
fracture, or when a limb has been 
carried away, lesions that are com- 
mon to impact from large projec- 
tiles or their fragments. Primary 
amputation as a result of gunshot 
fracture from the projectiles of hand 
weapons will be seldom required. 
A comminuted fracture of both 
bones with destruction of both tibial 
arteries would constitute a cause 
for amputation, but such an injury 
is seldom seen from the effects of 
hand weapons except in the case of 
rifle shots delivered at close range 
exhibiting explosive effects, or as a 
result of shot from a shot gun de- 
livered at contact or thereabouts. 
Modern methods of treatment have 
materially modified military prac- 
tice concerning amputation of the 
leg. After the battle of Waterloo, Thompson recommended amputa- 
tion (1) when a ball had fractured both bones of the leg; (2) for gun- 
shot fracture near the knee or ankle with joint involvement; (3) 
when a ball was deeply lodged in the tibia; and (4) for fracture of 
the tibia with injury to the blood supply. In our Civil War the 
mortality for 5452 amputations of the leg was 32.9 per cent., while the 

26 




Fig. 153. — Skiagram from case of W. A. 
Leech, Co. "I," 3rd Wis. Vol. Inf., shot 
during Civil War 1861-65. Missile not 
stated. Recovery took place after much 
suppuration. Skiagram taken in 1911. A. 
M. School collection. 



402 



GUNSHOT WOUNDS 



mortality for 3938 cases treated without operative interference was 
13.8 per cent. 

Improvement as a result of conservative treatment had become evi- 
dent even in the days of the Civil War, since Otis shows in a tabular 
statement, in which there appear 2989 cases from the time of the Thirty 
Years' War to and including the Russo-Turkish War of 1876-77, which 
has a mortality rate of 18.5 per cent, or 4.7 per cent, greater than the 
results of our Civil War. But the remote and ulterior effects of con- 
servative treatment as practised at that time should not be forgotten. 
As late as 1881 the Reports of the Pension Examiners " are replete with 
accounts of extensive caries and necrosis with continued discharge, 
enlargement of the limb, irritable ulcers, overlapping with projection 
of fractured ends, outward or inward curvature, ankylosis of the 
knee or ankle or both, contraction of toes, outward turning of foot 
giving the ankle the appearance of being dislocated, extensive and 
adherent cicatrices, atrophy and weakness, and inability to sustain the 
weight of the body" (Otis). 

(4) Secondary Amputation. — Sepsis and the complications to which 
it leads are the causes of secondary amputation. Secondary amputa- 
tions as compared to primary amputations constitute the bulk of the 
amputations in recent wars. In the days of the Civil War the term 
intermediary amputation was employed and it had reference to ampu- 
tations performed soon after the onset of acute inflammatory mani- 
festations. Under modern methods of treatment we combat cases 
showing active indications of sepsis and defer amputation if necessary 
to a time when efforts at conservation have entirely failed, so that our 
secondary cases appear proportionally larger in number than those in 
the American Civil War. The following are the number of amputa- 
tions of the leg at different periods and the mortality rate recorded 
by Otis: 





Amputations 


No. of 
recoveries 


No. of 
deaths 


Per cent. 


Primary 

Intermediate 

Secondary 


3392 

1046 

444 


2307 
682 
327 


1032 
364 
117 


30.9 

34.75 

26.3 


Totals 


4882 


3316 


1513 


30.98 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 403 

If we compare the total number of amputations of the leg and their 
death rate from the Government returns for the Spanish- American 
and Boer Wars we find as follows : 



War 


Cases operated on 


Died 


Death rate 


Spanish-American 

Anglo-Boer 


15 
32 


2 
8 


13 . 3 per cent. 
25 .0 per cent. 






Totals 


47 


10 


21.2 per cent 



The records show that nearly every one of the amputations in the 
last two wars was done as a result of sepsis. In other words they 
represent the class that would have figured under intermediate and 
secondary amputations in the Civil War. If we add these two to- 
gether in Otis' table we find a total of 1490 intermediary and secondary 
amputations with a total of 481 deaths or a mortality rate of 32.2 per 
cent, as compared to 21 per cent, for the Spanish-American and 
Anglo-Boer Wars. This gives 11.2 per cent, in favor of modern 
armament and antiseptic methods of treatment. The mortality after 
amputations of the leg in the Spanish-American and Anglo-Boer 
wars is entirely too high. Our object in making the foregoing com- 
parisons is to call renewed attention to the necessity of exercising 
greater care in battling against sepsis in war. Gunshot fractures of 
the long bones should be among the very first to receive the attention 
of surgeons and this should be carried out on the lines laid down 
under conservation in the large majority of the cases. 

The kind of amputation to be performed will depend upon the 
lesion to the soft parts. Speaking generally, as much of the limb 
should be retained as the injury will permit. When amputation is 
required for osteomyelitis the point of election is through the knee- 
joint, or the lower third of the femur. 

In dealing with the results of gunshot fractures in this chapter as 
far as they relate to the wars of the present, we have confined ourselves 
largely to the Government reports of the Spanish-American and 
Boer Wars. Although the number of cases is not large, we believe 
that when the Government reports of larger wars like the Russo- 
Japanese and Turko-Balkan Wars are available the results in the 



404 GUNSHOT WOUNDS 

United States and English reports will very nearly represent the 
conditions in more recent wars. We have never laid much stress 
upon the reports of isolated observers from any of the later wars, 
because the general results of war wounds can only be estimated after 
due consideration of the sum total of wounds received, and for some 
time after cessation of hostilities. 

GUNSHOT WOUNDS OF THE FOOT 

In our Civil War Otis records 5832 gunshot fractures of the foot 
and 11,369 fractures of the bones of the hand. The bones of the foot 
suffered one-half as often as those of the hand. It is safe to predict 
that this proportion will be much less hereafter. While fighting under 
cover in modern tactics, the foot is one of the least exposed parts of 
the body, while the hand is exposed as much now as formerly. 

Infection is prone to occur in gunshot wounds of the foot in the 
military service especially. The opportunity to dress the cases in 
active campaign is often delayed so that dirt from the shoes, or boots, 
and stockings driven in by the bullet has infected the wound before 
the application of a suitable dressing has been made. Once inflam- 
mation has gained access to the wound, it is difficult successfully to 
combat its spread because of the intimate relation between the bones 
and joints of the tarsus and metatarsus. Fractured bones, when 
exposed to inflammation in such inaccessible regions, are apt to undergo 
necrosis and exfoliation. The inflammatory process is often prolonged 
in spite of the active measures of treatment that are instituted. The 
effects in the end are toward ankylosis of the ankle and adjacent 
joints, loss of the arch and utility of the foot for walking. 

The mortality of gunshot fractures of the foot in our Civil War, 
largely as a result of sepsis, aggregated 8.3 per cent.; and 7.8 per cent, 
in the Franco-German War of 1870 and '71. 

Out of 158 cases of gunshot fractures of the metatarsus and toes 
reported by the Surgeon-General, U. S. Army, for the years 1898 to 
1900 inclusive, there were but three deaths, and two of these are 
ascribed to other causes. Reduced-caliber bullets were responsible 
for fifty of the cases, and two to shell fragments. One hundred and 
eighteen were restored to duty; sixteen were discharged for disability 
and the others were discharged by order, expiration of term of service, 
etc. 

In spite of the efficiency of the modern treatment of gunshot 



GUNSHOT INJURIES OF THE DIAPHYSES OF THE LONG BONES 405 



wounds, Stevenson reports fourteen septic cases out of thirty-two 
gunshots of the tarsal and metatarsal bones in the Anglo-Boer War. 
There were no deaths, twenty-four were inflicted by rifle bullets, 
seven by shell. Twelve cases exhibited perforation, there was 




Fig. 154. Fig. 155. 

Fig. 154. — Shows the result of a transverse shot through metatarsal bones of foot in a soldier at 
Santiago by a Mauser bullet. Radiogram was taken 22 months after injury. Callus formations 
were painful in sole of foot on walking. 

Fig. 155. — Shows foot after we had amputated two toes and part of corresponding metatarsal 
bones, Fig. 154. Radiogram taken 25 months after injury. Army Medical School collection 
U. S. Soldiers Home X-ray Laboratory. Dr. A. B. Herrick, X-rayist. 

grooving in five, and comminution in thirteen. The condition of 
the foot was good in five, and bad in six cases. Primary amputation 
was performed in the shell cases, and there were two secondary 
amputations through the leg. 



406 



GUNSHOT WOUNDS 



Treatment. — Conservation is to be employed in the large majority 
of gunshots of the foot. Primary amputation is indicated in nearly 
all cases resulting from shell fragments. The mode of amputation 

will depend upon the amount of 
destruction of bone and soft parts. 
The classical operations of Hey, 
Chopart, or Syme are usually 
employed. 

Secondary excision may become 
necessary when conservation fails, 
in which case the removal of the 
foyer of suppuration will have to be 
practised. This may include any 
part of the foot. Painful callus is 
another cause for partial excision. 
Transverse shots across the foot by 
modern rifle bullets are attended 
with many displaced fragments and 
resulting callus, for the relief of 
which operative interference at times 
becomes necessary (Figs. 154, 155). 
Hemorrhage from the larger 
vessels traversing the sole of the 
foot is not an infrequent complica- 
tion. Bleeding from such a source 
is best controlled by tying both ends 
of the injured vessel. Pressure is 
uncertain except for hemorrhage 
from the smaller vessels, and ligation 
of the anterior and posterior tibials 
is apt to end in gangrene. 

The greatest care should be em- 
ployed in cleansing the wound and 
the surface adjacent to it before ap- 
plying the first dressing. Explora- 
tion should be avoided except for the removal of missiles or loose bone 
fragments. After the application of a sterile dressing immobilization 
should be applied. 




Fig. 156. — The following case is of 
special interest to recruiting officers. Pvt. 
Raymond H. R. Co. "H" 13th Inf. A .22 
cal. rifle bullet lodged in metatarsal bone 
great toe, accidentally inflicted; detected 
by X-ray two years after enlistment. Was 
admitted to sick report for "arthritis sub- 
acute, metatarso-phalangeal joint great toe." 
Army Medical School collection. X-ray 
Laboratory, Fort Leavenworth, Kansas. 



CHAPTER XIII 

Casualties of Battle 

The radical changes that have taken place in the implements of 
warfare in recent years have brought about corresponding changes in 
the character of war wounds, the percentage of losses in campaigns, as 
well as in the ratio of killed to wounded. The changes thus wrought 
and the probable casualties indicated will be of special interest to the 
military surgeon in the wars of the future, since they will be used as a 
guide in providing supplies and personnel for the care of the wounded 
on the field and in field hospitals under modern conditions. 

The characteristic features of wounds and the percentage of killed 
and wounded to the number of men actually engaged in battle, in 
recent times have been modified more especially by the use of reduced 
caliber rifles and the effective use of field artillery. The kind of wounds 
inflicted by the latter and the hand rifles have been discussed at length 
in preceding chapters and they need no further comment here. 

The following table from Longmore has been used by nearly all 
writers on military surgery when dealing with losses in battle before 
the advent of reduced caliber rifles, machine guns and modern field 
artillery fire. 

A casual inspection of this table would indicate that the percent- 
age of losses in killed and wounded was much greater in the earlier \^ 
and middle parts of the 18th Century when the imperfect smooth 
bores were in use, and that these percentages have become lower with 
the perfection in the manufacture of firearms up to the time of the 
Franco-Prussian War when the effective military rifle of the needle 
gun and Chassepot type were used. As a rule soldiers fought stand- 
ing in earlier times and if they had continued to employ the same 
tactics, it is self-evident that the casualties of battle should have in- 
creased as the trajectory of bullets was made flatter, and the danger 
space was increased. Tacticians foresaw the slaughter that must 
ensue with the gradual perfection of firearms and for that very reason 
they wisely changed their mode of fighting from close to open order, 
from the standing to the prone position and as much as possible to 
fighting behind shelter, thus to avoid the chances of being hit by the 

407 



408 



GUNSHOT WOUNDS 



rapidity of modern fire and the increase in casualties from the superior 
penetration of the rifle bullet, and its longer continued danger space. 
These reasons at once set aside the notion that the diminution in the 
percentage of battle losses as shown in Longmore's table is due to ad- 
vances in the manufacture of firearms per se. Battles which may 
be fought with the use of present armaments at short range, in the 
open, and in close formation, will exceed all calculations in percentages 
of casualties by the old armaments, and the losses will approach 
annihilation. 

MODIFIED TABLE FROM LONGMORE SHOWING THE LOSSES PER 
CENT. OF STRENGTH IN VARIOUS BATTLES 



Battles and dates 



Strength 



Total loss, 
per cent. 



Blenheim, 1704 

Kunnersdorf , 1759 

Talavera, 1809 

Vittoria, 1813 

Leipsic, 1813 

Waterloo, 1815 

Alma, 1854 

Inkermann, 1854 

Crimean War, 1853-56 

Solferino, 1859 

Gettysburg, 1863 

New Zealand War, 1863-66. . 
Prusso-Danish War, 1864. . . . 

Weissenburg, 1870 

Woerth, 1870 

Gravelotte, 1870 

Franco-German War, 1870-71 
Beaune-la-Rolande, 1870 



British and Allies 

Gallo-Bavarians 

Prussians 

British 

British and Portuguese 

British alone 

Allies 

French 

British 

English 

Russians 

English 

French 

Russians 

English 

French 

Austrians 

Unionists 

Confederates 

British 

Prussians 

Germans 

Germans 

French 

Germans 

French 

Whole German Army. 
Germans. 



56,000 

60,000 

40,000 

22,000 

60,486 

35,129 

300,000 

171,000 

36,240 

21,481 

60,000 

14,000 

41,000 

55,000 

97,864 

135,234 

163,124 

117,350 

68,352 

7,930 

46,000 

106,928 

167,119 

46,000 

278,131 

125,000 

887,876 

91,405 



23.0 

66.0 

65.0 

24.6 

7.6 

9.4 

16.0 

36.0 

23.3 

9.3 

9.3 

20.1 

4.5 

28.6 

15.1 

12.7 

13.6 

19.7 

46.2 

8.6 

5.3 

1.4 

6.3 

36.9 

7.3 

8.0 

13.2 

0.95 



CASUALTIES OF BATTLE 409 

The first battle of any consequence, in which the opposing forces 
were armed with the reduced caliber military rifle carrying the steel- 
jacketed bullet, was the battle of Santiago de Cuba in the Spanish- 
American War on the 30th of June, 1898. Out of 11,000 men engaged 
on the American side there were 1400 wounded and 233 killed, or a 
casualty list of 1633 killed and wounded which places the battle losses 
at 14.8 per cent. The battle was fought on a terrain partly covered 
with underbrush, and the troops sought shelter wherever this was 
available in accordance with modern tactics. Neither side was pro- 
vided with much field artillery and the number of wounds by shell 
fragments or shrapnel was very insignificant. 

The average of the ratios of Longmore's table is about 17 per cent, 
as compared to 14.8 per cent, for the battle of Santiago. If we ex- 
amine Longmore's table again, we find that individual battles show 
great variation in the percentage of casualties. At Koniggratz in 
1866 the Prussian loss was but 4.1 per cent., at Gravelotte it was 
7.3 per cent., and at Sedan it was again low, only 4.7 per cent., while 
at Weissenburg in 1870 the total loss of the Germans was but 1.4 
per cent. But the lowest casualty rate of all for the Franco-German 
War was at LeMans in 1871, when the Germans lost 0.23 per cent, 
killed and 0.72 wounded. 

In the days of smooth bores we find great variations in the total 
casualties of battle as we do in more modern times. At Waterloo out 
of 36,240 men engaged the British loss was 23.3 per cent. At Vittoria 
in 1813 out of 60,486 men engaged the British and Portuguese loss 
was 7.6 per cent., while the British loss alone was 9.4 per cent, out of 
35,129 troops in battle. At Leipsic in the same year out of 300,000 
the allies loss was 16 per cent., while out of 171,000 the French loss 
was 36 per cent. 

The following table 1 gives the casualties in a number of the battles 
in our Civil War 1861-65, and the Franco-German War 1870-71. 

The military rifle of this period is represented by the breech-loading 
rifle known as the Minie and Enfield rifles, used in the Civil War, 
which fired a lead projectile from .69 to .59 calibers, and with initial 
velocity of about 1000 f.s., an effective range of 1000 to 1300 yards; 
and the Chassepot and needle-gun used in the Franco-German War, 
which carried a lead projectile of about .45 to .50 calibers, initial ve- 
locity 1100 to 1300 f.s., and extreme range of about 1500 yards. The 
large majority of wounds were inflicted by the military rifle, the cut- 

1 Battle losses of the Campaign in Manchuria by Louis C. Duncan, Captain, 
M. C, U. S. A., J. Mil. Service Inst., Vol. LV, No. 192. 



410 



GUNSHOT WOUNDS 



ting implements and artillery were probably not responsible for more 
than 8 to 10 per cent, of the casualties. 

UNION LOSSES, 1861-65 



Strength 


Loss 


Per cent. 


90,000 


11,657 


13.0 


100,000 


10,884 


10.8 


100,000 


23,000 


23.0 


50,000 


11,000 


22.0 


105,000 


16,000 


15.0 


, 1870-71 






65,000 


14,100 


22.0 


179,000 


19,700 


11.0 


165,000 


6,724 


4.1 



Antietam 

Fredericksburg . 
Gettysburg .... 
Chick amauga. . 
Wilderness .... 



Vionville-Mars la Tour. 
Gravelotte-St. Privat . 
Sedan 



This table is of special value because the strength of the armies 
engaged is given from which the percentage of losses may be computed. 
The average of the ratios here given is 8.9 per cent, as compared to 
17 per cent, in Longmore's table. 

The absence of exact figures as to the number of men engaged in 
battle prevents us from comparing the casualties in battles of very 
recent times, with those just referred to. We can, however, make 
approximate estimates by noting the casualties for the whole of each 
of the recent wars. 

If we first take the Spanish- American War among the later wars in 
which modern armament in the hands of foot troops played the prin- 
cipal role, we find a total casualty list of 7048. The army in the field 
was 350,000 men. The war was merged into the Philippine Insurrec- 
tion which lasted from 1898 to 1902. The larger part of the army was 
employed in guarding lines of communication, in garrisoning forts, 
ports, and towns away from the firing line so that it is more nearly 
correct to estimate the casualties for a strength of 100,000 which would 
give a percentage of approximately 7.0 per cent. 

The British casualties for the Boer War, in which the infantry arm 
caused nearly all the wounds, were 7.1 per cent. It is estimated that 
not more than 200,000 men were engaged in battle, making the per- 
centage of casualties for the entire war 14.2 per cent. (Stevenson). 

The casualties for the Russo-Japanese War in which modern arma- 



CASUALTIES OF BATTLE 411 

men! as represented by the use of the military rifle, machine guns, 
shell, shrapnel, and hand grenades played a prominent part are set 
forth by H. Fischer in Kriegschirurgische Riick-und Ausblicke vom 
Asiatischen Kriegsschauplatze. In culling data from the Russo- 
Japanese war we will make free use of the matter in Fischer's article 
and that of Captain Duncan already referred to. 

The Japanese mobilized 1,200,000. The number which took the 
field was 650,000 and the number actually engaged in battle was 
540,000. There were 47,400 killed and 173,400 wounded, total casual- 
ties 220,800 or 34 per cent. 

The Russians mobilized 1,365,000. The number taking the field 
was 699,000 and the number taking part in battles was 590,000. 
There were 28,800 killed, and 141,800 wounded, total casualties 
170,600 or 28 per cent. 

The casualties in this war on both sides sets at rest the notion that 
war has become less deadly with the perfection of armament. The 
ratio of casualties by the rifle and artillery fire before the advent of the 
magazine reduced caliber rifle and the perfected field artillery was for 
the decade 1861-71 as follows: 

Rifle Artillery 

Civil War (Union forces) 90 . 1 9.8 

Franco-German War 1870-71 (German) . 91.6 8.4 

For the Russo-Japanese War. 

Japanese 83 . 5 13.5 

Russian 84 . 5 14.5 

The casualties inflicted by machine guns in the Russo-Japanese 
War are included in those credited to the infantry rifle since the weapons 
employ the same ammunition and the characteristic features of the 
wounds from these two sources cannot be differentiated. The deadli- 
ness of the hand grenade was terrific when the explosion took place 
where the men were crowded together. The grenade was employed 
at close quarters. It is estimated that it caused 0.2 per cent, of wounds 
on the Japanese side. The number of wounds by saber and lance was 
negligible. The bayonet wounds numbered 1.7 per cent, in the Japa- 
nese Army, .4 per cent, among the Russians as compared to 6.17 
per cent, in the German and Union Armies in the Franco-German 
and Civil Wars. 

The casualties by artillery fire in the Russo-Japanese War, which 
refers almost exclusively to shrapnel shells from 3-inch field guns, were 
the greatest ever noted. In some of the battles the casualty list by 



412 GUNSHOT WOUNDS 

this arm was especially large. Brentano places it at 33 1/3 per cent, at 
Mukden. The observers in the Turko-Balkan War 1912-13, in which 
the Bulgarians used shrapnel fire very effectively, report that the per- 
centage of shrapnel wounds in the Constantinople hospitals was very 
large. In the hospitals visited by Lucas Championniere 1 80 per cent, 
of the wounds were inflicted by shrapnel. 

The Proportion of Killed to Wounded. — The proportion of those 
killed to the number wounded depends on a number of factors. After 
careful study of the statistics of wars fought hitherto, Longmore esti- 
mates that the average proportion of those killed or found dead on 
the field to the number wounded is 1 to 4. But this proportion is very 
much influenced by the mode of attack. A frontal attack in close 
formation against a rapid effective fire will add to the proportion of 
killed to wounded from the multiplicity and gravity of wounds at 
proximal ranges. Fighting from entrenched positions or behind cover 
on the field is one of the principal factors in increasing the number of 
killed to wounded. In the Russo-Turkish War where much of the 
fighting was done against entrenched positions the proportion of killed 
to wounded among the Russian troops was 1 to 2.1. At Blenheim 
there were nearly as many killed as wounded — 1 to 1.3. 

More dead are found on the field after long battles lasting several 
days than short battles of one or two days as shown by the following 
table from Matignon: 

Yalu 1 day, 1 killed to 5 . 7 wounded. 

Josheli 2 days, 1 killed to 5 . 02 wounded. 

Matieling 4 days, 1 killed to 4 . 02 wounded. 

Liaoyang 10 days, 1 killed to 5.02 wounded. 

Mukden 13 days, 1 killed to 3 . 09 wounded. 

In the Spanish- American War the ratio of killed to wounded was 
1 to 5.6. In the Boer War the ratio was 1 to 3.9, or an average of 1 to 
4.7 for the two wars. The fighting in these two wars was done at 
long range, there were no siege operations of any consequence and the 
battles were comparatively small and of short duration. 

In the Russo-Japanese War the ratio of killed to wounded on the 
Japanese side was 1 to 3.6, and on the Russian side the ratio was 1 to 
4.9. In the German army in the Franco-German War the ratio was 
1 to 5.8; and in our Civil War it was 1 to 4.7. The influence of fighting 
behind entrenchments which is usually more deadly since the head 

1 Op. cit. 



CASUALTIES OF BATTLE 



413 



and upper portions of the body are the only parts exposed, is well 
shown among those hit in Port Arthur where the ratio of killed to 
wounded was 1 to 2. 

Influence of Modern Treatment on Losses in War. — The benefi- 
cence which comes from the modern treatment of gunshot wounds as 
compared to the woeful experience of the preantiseptic era is well 
shown in the following table : 



Japanese 

Russian 

J^erman, 1870-71 
Union, 1861-65.. 



Killed 



Died 



Total 



Wounded 



47,400 
28,800 
17,300 
67,058 



11,500 

5,200 

11,000 

43,012 



58,900 

34,000 

28,300 

110,070 



173,400 

141,800 

99,600 

300,000 



Wounds by the different engines of war are very interesting 



Firearms, 
per cent. 



Bayonets, 
per cent. 



Stones 



Grenades, 
per cent. 



Japanese 97.0 

Russians 98 . 3 

Germans (1870-71) 99 . 4 



1.7 

0.4 
6.0 



1.3 
0.7 



0.2 



Wounds by Military Rifle and Artillery Fire. — The efficiency of 
artillery fire in the open in modern times has come forth very promi- 
nently in reckoning the casualties of battle. Casualties from this 
source have always figured extensively in siege operations and where 
the fighting has occurred behind entrenchments. The following table 
shows the percentage of wounded by the two arms in former wars as 
compared to those in the Manchurian campaign. 

For the Manchurian campaign the table shows that the military 
rifle has lost some of its prestige, and yet its efficiency was as promi- 
nent as ever in certain battles. 

The Russian wounded by the rifle at Sandepu was 94 per cent.; at 
Yalu 89 per cent.; at Shaho 78 per cent. 



414 GUNSHOT WOUNDS 

WOUNDS FROM MILITARY RIFLE AND ARTILLERY FIRE 





No. wounded 
in 


Small 

arm 

bullets, 

per cent. 


Grape shot 

grenades, 

shell, 


Remarks 




hospitals 


shrapnel, 
per cent. 




Crimean War, 1853-56. 








During Crimean 


French Troops (Chenu) 


34,306 


53.4 


46.6 


War the ma j ority 


British troops after at- 


1,657 


60.53 


39.47 


of wounds oc- 


tack Great Redan 








curred among 


Sebastopol 








besiegers in the 
trenches before 
Sebastopol. 


Italian campaign, 1859. 


15,383 


94.2 


4.9 


In this war there 
were no siege op- 
erations. The 
principal battles 
took place in the 
open. 


U. S. Civil War. 1861- 


Nature missile 


91.1 


8.9 


Battles in this 


65 (Otis) 


ascertained 
in 141,961 
gunshot 
wounds 
Union side. 






war were mostly 
in the open with 
some siege opera- 
tions. 


Franco-German War 


Nature mis- 


88.7 


11.3 


Nature of the 


1870-71. (Fischer.) 


sile ascer- 
tained in 
53,482 gun- 
shot wounds 
German side. 






fighting very 
much that in our 
Civil War, 1861- 
65. 


Russo-Japanese : 








Outside of Port 


For the entire war 








Arthur the fight- 


(Japanese) 


173,400 


83.5 


13.5 


ing in this war 


(Russian) 


141,800 


84.5 


14.5 


was in the open. 



The Japanese wounded by the rifle at Yalu 97 per cent. At 
Saiken it caused but 70 per cent, of the wounds. 

The efficiency of the artillery arm is well shown at Port Arthur 



CASUALTIES OF BATTLE 415 

where the wounded on the Japanese side from this source amounted to 
21 per cent., while the military rifle and machine-gun caused 72 per 
cent., the bayonet, hand grenades, stones, etc., caused 6.57 per cent. 

The efficiency of the different arms is again summed up by Fischer 
as follows: 

The Japanese infantry (87.6 per cent, of the army) caused 84.5 
per cent, of Russian wounds. 

The Japanese artillery (8.7 per cent, of the army) caused 14.5 
per cent, of Russian wounds. 

The Japanese cavalry (4.64 per cent, of the army) caused (with 
saber and lance) a loss so small as to be not worth setting down. The 
efficient value of the various troops, for wounding, was about the same. 

The Russian infantry (84.8 per cent, of the army) inflicted 83.5 
per cent, of Japanese wounds. 

The Russian artillery (9.3 per cent, of the army) inflicted 13.5 
per cent, of Japanese wounds. 

The Russian cavalry (5.9 per cent, of the army) inflicted .04 per 
cent, of Japanese wounds. 

The losses by machine guns, and carbine are included in those 
credited to infantry since the ammunition is the same and the wounds 
caused by them cannot be differentiated. 

The Regional Distribution of Wounds. — The changes which may 
have resulted in the regional distribution of wounds as a result of 
changes in tactics and armament in recent years are more or less pointed 
out in the results noted in the Russo-Japanese War by Fischer, 
Duncan, Schaefer and others. 

According to Chenu's table which is based on a study of the dis- 
tribution of wounds on the target area of the body among many 
thousands of hospital wounded in former wars, the average distribu- 
tion is approximately as follows: 

All projectiles 
Wounds of included 

Head, face and neck 8 . 56 

Trunk 17.56 

Upper extremity 23 . 56 

Lower extremity 48 . 30 

Total 97.98 

If we compare this table with the results in wars which commenced 
to mark the effectiveness of the armaments which in turn caused 



416 GUNSHOT WOUNDS 

soldiers to fight under cover we find that the percentages of hits for the 
upper part of the body has been increased and that the number of 
wounds for the lower part has correspondingly diminished. This is 
well shown if we make the comparison between the Franco-German and 
Russo-Japanese Wars. 

German, Japanese, 

1870-71 Matignon 

Head and neck 12.2 20-25 

Body 11.1 25-30 

Upper extremities 35.5 25-30 

Lower extremities 41 . 2 30-35 

Head and body 23 . 3 45-55 

Extremities 76. 7 55-65 



If the average percentage of killed to wounded on the field is esti- 
mated on a basis of 1 to 4, in war, according to this ratio and Matig- 
non's table referred to, for every 1000 casualties there should be 200 
killed, 160 wounds of the head and neck, 200 wounds of the body, 
200 wounds of the upper extremity and 240 wounds of the lower 
extremity. 

According to Schaefer, 50 per cent, of wounds of the upper extrem- 
ity were of the index-finger and thumb. Duncan estimates that the 
gravity of the wounds and care required should be rated at about 
80 per cent, for the head and body, and 20 per cent, less for the 
extremities. 

Wounds by regions in different arms of the service are noted as 
follows by Schaefer: 





Infantry 


Artillery 


Cavalry 


Head and neck 


16.17 
17.49 
32.18 
33.53 


18.74 
18.74 
27.75 
34.77 


13.85 


Body 

Upper extremities 

Lower extremities 


24.61 
20.00 
41.54 



The same author gives a table of wounds by regions from different 
weapons in Russian hospitals during Russo-Japanese War as follows : 



CASUALTIES OF BATTLE 



417 





Rifle 


Shrapnel 


Shell 


Grenade 


Head and neck 


13.10 
18.25 
33.80 
34 . 85 


18.69 
17.88 
26.86 
36.57 


32.86 
13.31 
29.81 
24.02 


31.82 


Body . 

Upper extremities 

Lower extremities 


13.53 
24.21 
33.53 



Shrapnel, shells and grenades caused an excessive number of head 
wounds and doubtless a greater number of deaths. 

It is apparent in all the tables that the lower extremity is hit more 
often than the upper. Why this should be so in modern wars when 
men seek to fight behind cover and entrenchments is not clear. In the 
same way it is puzzling to find that men who fight lying down are 
hit in the lower limbs more often than those who fight kneeling. The 
following table by Schaefer shows this to be a fact, and it also shows the 
preponderance of wounds of the head, body and- upper extremities in 
those who fight in the kneeling and prone position: 



Standing 



Kneeling 



Lying 



Head and neck . . . 

Body 

Upper extremities 
Lower extremities 



11.04 
16.42 
32.47 
40.07 



18.17 
21.69 
35.98 
24.16 



14.87 
19.69 

36.81 
28.63 



Gravity of Wounds by Weapons. — Schaefer shows that shrapnel 
causes twice as many serious wounds as shell fragments: 

Of 1347 light artillery wounds 45 per cent were made by shrapnel. 

54 per cent, were made by shell fragments. 
Of 358 severe artillery wounds 62 per cent, were made by shrapnel. 

38 per cent, were made by shell. 

Shrapnel made almost twice as many serious wounds as shell 
fragments. 

Fatality from gunshot wounds of different regions is variously 
estimated, but as noted in former wars, first head, and next body 
wounds, are most fatal. The low recorded mortality from wounds of 
the extremities is noteworthy. 

27 



418 GUNSHOT WOUNDS 

The regions in which wounds caused death were estimated as follows : 

By By 

Von Haga Matignon 

Head and neck 54 . 02 59 

Body 44.45 34 

Extremities 1.52 7 

Artillery wounds causing death were estimated : 

Head and neck 59 . 00 54 

Body 34.55 44 

Extremities 6.36 2 

Wounds of Right and Left Side of Body. — In the act of firing the 
soldier exposes the left side of the body more often and the percentage 
of hits in the extremities has favored the left side. For the Franco- 
German War 1870-71 the ratio was R. 46.4; L. 53.6. In the late Man- 
churian campaign of 7631 bullet wounds noted by Schaefer the ex- 
tremities were hit in 5187 instances: R. 48 per cent., L. 52 per cent. 

Regimental Losses. — Regimental losses from modern armament 
exclusive of the present European War have not exceeded those of 
former times in spite of the reported slaughter of Japanese troops dur- 
ing frontal attacks in mass in Manchuria. 

In the Franco-German War 1870-71, at Mars-la-Tours the third 
Westphalian Infantry lost 85 per cent.; the Sixth Brandenburg and 
Second Schleswig each lost 65 per cent. Duncan notes that the losses in 
our Civil War 1861-65 were even greater. At Gettysburg the Twenty- 
fourth Michigan lost 83 per cent.; the First Minnesota 81 per cent., the 
Twenty-sixth North Carolina (Confederate) lost 85 per cent. 

Fischer gives the following losses for Russian and Japanese regi- 
ments in the Manchurian campaign. 

Russian. 

Third Rifle Regiment at Sandepu 66 per cent. 

First Rifle Regiment at Mukden 61 per cent. 

Fourth Rifle Regiment at Sandepu . . . 53 per cent 

Fourth Rifle Regiment at Shaho 40 per cent. 

Japanese. 

Eleventh Infantry at Mukden 68 per cent. 

Twenty-first Infantry at Mukden 56 per cent. 

Forty-first Infantry at Mukden 39 per cent. 

Forty-second Infantry at Mukden 62 per cent. 

Percentage of Fatalities in Wounded which Reach Hospital Care. — 

Hospital mortality among wounded as this may be influenced by 
modern surgical methods and the new armament, compared to pre- 



CASUALTIES OF BATTLE 



419 



antiseptic times and the use of the old armament, is well shown by 
the statistics of the Russo-Japanese War. 

If the comparison is made with the Franco-German and our own 
Civil War we find as follows: 



Killed 



Wounded 



Died of 

wounds 



Per cent. 



Japanese 

Russians 

Germans, 1870. 
Union, 1861-65 



47,400 
28,800 
17,300 
67,058 



173,400 

141,800 

99,600 

300,000 



27,200 

9,300 

11,000 

43,012 



6.4 

3.7 

11.0 

14.6 



We may take for granted that the losses in our Civil War and the 
Franco-German War were about the average of those in war hospitals 
in preantiseptic times. There is a striking difference, 50 per cent., 
between the hospital mortality of the Russian and Japanese as shown 
in the table herewith. Considering that the surgical methods were 
practically the same for these two nations well-advanced in surgical 
knowledge, and that the armaments employed were essentially the 
same, there should be more uniformity in their hospital results. 

It is said that in the earlier part of the war the Russians exercised 
great pains in promptly carrying the wounded off the field by com- 
batant comrades, while this relief work on the part of the Japanese 
was left entirely to the Hospital Corps which for lack of numbers in 
great battles always failed in clearing the field promptly. As a conse- 
quence tardy surgical relief caused deaths from hemorrhage and the 
development of infection, which together added greatly to the loss of 
life in war hospitals. 

Casualties in the Present European War. — Battle casualties are 
very difficult to obtain during a war. This is notably the case in the 
present conflict. In highly organized countries, deaths and casualties 
are often published in lists, by name. The interests of the state 
frequently do not permit such publications. Germany and England 
are the only governments that have given out information of losses, 
and these have been but fragmentary. France has withheld all 
reference to casualties in her published reports. 

From the censored reports that have come from some of the 



420 



GUNSHOT WOUNDS 



governments, from newspaper and magazine reporters, attaches, etc., 
we have gathered estimates that cannot fail to be of interest, and they 
are as reliable as anything which is now available on the subject. 

General Francis Vinton Greene formerly in the United States Army, 
a well-known military critic, in a lecture delivered at Cullum Hall, 
West Point, October 7, 1914, gave the battle casualties as well as he 
could gather them at that time. From official reports which have 
been summarized, the population on the side of the allies in Europe is 
226,500,000, as compared with 122,200,000 of the Teutonic Nations, 
and their ally, Turkey. The Colonies of the allies have a population 
of 472,500,000 people as compared with 32,800,000 in the Colonies 
that now, or did, belong to Germany, Austria, and Turkey. The total 
population upon which the allies can draw is 739,000,000 as compared 
with 155,000,000 who owe allegiance to the Kaiser, Emperor of Austria, 
and the Sultan. 

General Greene gives a table of "Armed Strength" which is based 
on figures obtained from various standard works. These figures are 
approximate onty, but probably sufficiently accurate for comparative 
purposes. The table which gives both the army and naval totals 
of the powers at war is as follows: 



ARMED STRENGTH 



Armies 



Navies 



Peace 



War 



Ships I Tonnage 



Great Britain. . . 

France 

Russia 

Italy 

Belgium 

Serbia 

Total 

Germany 

Austria Hungary 
Turkey 

Total 



156,000 

800,000 

900,000 

270,000 

45,000 

25,000 



2,196,000 
800,000 
340,000 
220,000 



700,000 

2,780,000 

2,600,000 

1,500,000 

170,000 

190,000 



1,360,000 



7,940,000 

3,500,000 

1,400,000 

360,000 



5,260,000 



545 
368 
241 
183 



1,337 

304 

124 

41 



469 



2,700,000 
900,000 
680,000 
500,000 



4,780,000 

1,300,000 

350,000 

? 100,000 



1,750,000 



CASUALTIES OF BATTLE 



421 



The following table of casualties since the beginning of the present 
war was completed from official reports made in the House of Com- 
mons and from data gathered from other sources. The figures are 
not much more than intelligent guesses, but General Greene states 
that he used minimum figures: 

LOSSES IN BATTLE 





Killed 


Wounded 


Missing 


Total 


Great Britain 


86,000 

400,000 

500,000 

5,000 

25,000 

20,000 


251,000 

700,000 

800,000 

15,000 

40,000 

40,000 


55,000 

300,000 

900,000 

5,000 

15,000 

10,000 


392,000 


France 

Russia 

Italy 

Belgium 

Serbia 


1,400,000 

2,200,000 

25,000 

80,000 

70,000 


Total 

Germany 

Austria 

Turkey 


1,036,000 

600,000 

400,000 

30,000 


1,846,000 

1,000,000 

700,000 

80,000 


1,285,000 

300,000 

700,000 

20,000 


4,167,000 

1,900,000 

1,800,000 

130,000 


Total 


1,030,000 


1,780,000 


1,020,000 


3,830,000 



The Outlook, August 12th, gives the following for all powers en- 
gaged up to July 1 7 1915. 



France 

Great Britain 

Russia 

Germany .... 

Austria 

Belgium 

Serbia 

Turkey 

Japan 

Total 



Killed Wounded 



Prisoners 
or missing 



Total 

casualties 



400,000 

116,000 

733,000 

482,000 

341,000 

47,000 

64,000 

45,000 

300 



2,228,300 



700,000 

229,000 

1,982,000 

852,000 

711,000 

160,000 

112,600 

90,000 

910 



300,000 

83,000 

770,000 

233,000 

183,000 

40,000 

50,000 

46,000 



4,837,510 



1,705,000 



1,400,000 

428,000 

3,485,000 

1,567,000 

1,235,000 

247,000 

226,600 

181,000 

1,210 



8,770,810 



422 GUNSHOT WOUNDS 

It is difficult to determine the ratio of killed to wounded. One of 
the military experts has calculated that in the battle of the Marne, the 
ratio was approximately as formerly, 1-4 1/2. . In the trench fighting 
that is now taking place on the Western front the wounds are inflicted 
in the upper port of the body in the majority of the cases, and there, 
the ratio of killed to wounded is estimated at 1-3. 

The Army and Navy Journal of September 11 quotes Premier 
Asquith as stating that the death rate among wounded has been 24 
per cent., due to trench fighting and shrapnel wounds. The same 
journal also quotes Sir William Osier who states that in the first ten 
months of war the number of killed was 50,432, wounded 153,980. 
Of the latter, 60 per cent, were returned to duty. 

A military critic of note, writing February 2, 1916, states that 
there are no lists of casualties that give accurate data. Germany 
omits to publish slight wounds; France publishes no list at all; the 
Russian lists are defective; in all lists the same name may occur 
more than once. 

The same authority has compiled data on wounds caused by the 
various weapons. In an advance by a French Army Corps which 
bore the brunt of the attack the following figures were obtained : 

70 per cent, shell and shrapnel, 

5 per cent, (blowing up trenches), 

14 per cent, small-arms, 

0.5 per cent, bayonet, 

3.5 per cent, hand-grenades, 

7 per cent, unknown. 

The latest and what is considered the most reliable in the way of 
data on battle casualties has been given out recently at Copenhagen 
by the Society for the Study of the Social Consequences of the War. 
The calculations are based on the official reports as far as they are 
obtainable, and the Society expressly states that the estimates are 
"very conservative:" 

According to the British War department from August 1, 1914, to 
July 31, 1916, England has lost 34,360 officers of whom 11,655 were 
killed, 19,343 were wounded and 3,462 were captured or missing. 
From these data the society calculates a minimum British loss of 
808,468 officers and men, divided as follows: dead, 188,464; wounded, 
512,465; captured or missing 107,543. 

The British Navy up to July 31, lost 18,777 men, the number dead 
being 16,983. 



CASUALTIES OF BATTLE 423 

Germany has about 33,000 English prisoners, Turkey 17,827 and 
Bulgaria 449. 

French Losses. — France makes no published reports, and the data 
of the society were obtained from the Red Cross and other reliable 
sources. The estimates show that 870,000 French soldiers have been 
killed, 624,000 totally disabled and 2,080,000 less seriously wounded; 
while about 400,000 have been captured or are missing, making a 
total of 3,974,000. 

The losses of Germany, the only nation of the belligerents which 
has regularly published detailed reports, are higher than those of the 
French. The German killed, numbered 893,311, badly wounded 
720,154, less seriously wounded 2,443,180, missing 245,000. The 
German total is thus brought up to 4,301,645 officers and men. 

Austria's Casualties. — According to official and other trustworthy 
sources Austria has lost 2,889,250 men. Of these 523,125 have been 
killed, 1,775,125 have been wounded, and 591,000 were captured and 
missing. 

The actual French, German and Austro-Hungarian losses are much 
smaller. In France 80 per cent, of the wounded returned to the colors, 
in Germany 90.5 per cent, and in Austria-Hungary 84.5 per cent. 

Italian Losses. — Italy keeps her casualties a secret, but it is esti- 
mated 105,000 have been killed, 245,000 wounded, and 55,000 cap- 
tured or reported missing. 

Belgium's Casualties. — During the first two years of the war, 
Belgium lost 200,000, of whom 50,000 were killed, and 110,000 were 
wounded. There are 40,000 Belgian prisoners in Germany. 

Serbia is supposed to have lost 400,000. More than 200,000 were 
captured by the Austrians and Bulgarians. A loss of 60,000 dead and 
160,000 wounded seems to be a conservative estimate. 

The Bulgarian losses before the renewal of the fighting in Mace- 
donia were small, amounting to about 7500 killed, 35,000 wounded 
and 6000 missing. 

Russia's Losses. — The greatest losses have been sustained by 
Russia. Semi-official reports, from August 1, 1914, to February 1, 
1916, show 900,000 Russian soldiers were killed, 187,000 died of 
wounds and 63,000 from diseases, 2,936,000 were wounded, 935,000 
became sick and 2,000,000 were captured and reported missing, mak- 
ing a total of 7,021,000. Since February the losses have been 
1,500,000 and the total to July must aggregate about 8,500,000. 

The combined casualties of the nations at war since the beginning 
of hostilities in August, 1914, total according to the society's figures 



/ 

/ 



424 GUNSHOT WOUNDS 

22,000,000. About 4,200,000, have been killed and 1,000,000 died 
from diseases; 1,500,000 were totally disabled and 3,800,000 have been 
captured or missing. 

The statistics do not include the casualties since August, 1916, 
which have been very great at many points. In all the carnage that is 
going on in the World War, the loss of the sanitary service of armies 
under modern conditions keeps apace. In the investigation insti- 
tuted in the House of Deputies on a proposition to increase the effi- 
ciency of the French Army, Mr. Navarre while remarking upon the 
personal valor of the Army Medical Corps, states that the statistics 
of battles show that "the officers of the Sanitary Service have paid a 
large tribute in this war. They have fallen by the side of our brave 
combatants in proportions equivalent to those of infantry officers.' ' 



CHAPTER XIV 

Medico-legal Phases of Gunshot Wounds 

The medico-legal phases of gunshot wounds require a consideration 
of certain points, with definite answers, as far as these are obtainable 
by evidence at the time of occurrence, and such evidence as may be 
adduced by a knowledge of firearms, projectiles, explosives, etc. 
The behavior of the last two on tissues and clothing at the time of 
discharge frequently affords evidence of the greatest value. The 
effects of projectiles and explosives on the body involve many problems 
that are submitted to the medical witness for solution which may be 
discussed under the following headings: 

1. Diagnosis of a Wound Caused by Firearms. 

2. At What Distance was the Firearm Discharged? 

3. When was the Wound Inflicted, Before or After Death? 

4. Is the Wound Dangerous to Life? 

5. The Practitioner's Liability in Case of Infection. 

6. How was the Wound Inflicted? 

7. Was it Accident, Suicide or Homicide? 

8. Identity of the Individual by the Flash of the Firearm. 

9. Self-inflicted Non-fatal Wounds. 

10. At What Time was the Firearm Discharged? 

11. Was the Projectile Jacketed or not? 

1. Diagnosis of a Wound Caused by Firearms. — The appearance 
of a gunshot wound is at times atypical and doubt arises as to whether 
the injury was the result of gunshot. Doubt is reasonable only when 
superficial bruise or abrasion is found. A gunshot wound is marked 
by a wound of entrance and most generally by a wound of exit. 

Wound of Entrance. — The skin wound of entrance corresponds to 
the diameter of the projectile inflicting it. At times the aperture of 
entrance appears smaller than the diameter of the projectile, but the 
difference is only apparent since the wound invariably admits a pro- 
jectile of like caliber to the one which has caused it. The smaller 
appearance is due to shrinking from the elasticity of the skin. Wounds 
inflicted in skin overlying bone or resistant aponeurosis will show a 

425 



426 GUNSHOT WOUNDS 

wound of entrance exceeding the size of the bullet. The edges of 
the wound may be scorched or not, depending on the proximity of 
the muzzle at the time of discharge and to the kind of powder used. 
Black powder which liberates its gases by ignition causes burning and 
tattooing with proximal shots; the nitro-cellulose powders and de- 
tonators do not cause burning, and tattooing is less marked. The lead 
bullets which were formerly lubricated left a dark coating about the 
edges of the entrance wound in the skin which simulated the ap- 
pearance of burning, but close inspection in such cases revealed the 
true nature of the discoloration. The edges of the entrance wound are 
more or less inverted, lacerated, bruised and surrounded at times by 
ecchymosis. The wound of entrance contains bony sand in some 
gunshot wounds from the reduced-caliber rifle when fracture of a 
resistant bone has taken place at the proximal ranges. The wound is 
rounded when the piece is held at some distance. When the muzzle is 
held at contact the skin is torn and lacerated. Bleeding is slight 
unless a vessel near the surface is injured, but bleeding is more often 
seen at the wound of exit. Direct impact causes a round wound of 
extrance, while tangential shots show oval skin apertures. A wound 
of entrance in skin overlying loose areolar tissue like the scrotum may 
appear much smaller than the projectile on account of the extreme 
elasticity of the skin in this region. Bullets from the high-power 
reduced-caliber rifles often show a mere slit in skin which is wrinkled, 
like that of the scrotum, neck or knee. 

Wound of Exit. — The exit aperture never exhibits tattooing, 
burning or other disfigurement from the powder charge. It is usually 
larger than the wound of entrance and in cases of bone lesion it may 
exceed the size of the projectile many times. It is more irregular than 
the wound of entrance. The edges of the wound are everted, and sub- 
cutaneous fat may protrude from it. In cases of gunshot fracture at 
proximal ranges by the reduced-caliber rifle, the wound of exit may be 
multiple from pieces of the bullet or particles of bone having been 
driven forth with the bullet as secondary projectiles. For reasons not 
easily explained there are cases in which the wounds of entrance and 
exit are so nearly alike that it is difficult to distinguish the one from the 
other. The wounds of entrance and exit of a jacketed bullet at proxi- 
mal ranges are very much alike when soft parts alone have been 
traversed. Low-velocity projectiles composed of lead are apt to be 
deflected and many instances are given of bullets following the 
contour of the body. The high-velocity military and sporting rifles 



MEDICO-LEGAL PHASES OF GUNSHOT WOUNDS 427 

of the present day shoot projectiles that travel in a straight line, and 
it is safe to assert that the channel of a bullet from these weapons is 
marked by a straight line drawn between the entrance and exit 
wounds when the parts have been placed in the position which they 
occupied when hit. 

Multiple wounds are common in shotgun injuries, and they give 
valuable evidence of direction when but one shot has been fired. As a 
result of superior velocity and penetration, multiple wounds from one 
shot are common with the present-day military and sporting rifles of 
reduced caliber. A man entered the hospital at Siboney, in the 
Santiago campaign, with six wounds inflicted by one Mauser bullet, 
implicating the right shoulder and both breasts. There were a number 
of instances in which wounds of the body were associated with wounds 
of the arm or forearm, or both, the latter being in a state of flexion 
at the time of injury. Capt 7th. Infantry, re- 
ceived four wounds of the face followed by no disfigurement. The 
projectile, a Mauser, entered the right cheek below the outer canthus, 
emerged on the nasal side. It next entered the right side of the nose 
and emerged on the opposite side. Wounds of entrance and exit in 
the upper thighs were several times complicated by wounds of the 
scrotum or penis by the same bullet. 

2. At What Distance was the Firearm Discharged? — The distance 
between the muzzle of the weapon and the point of impact is one of 
the most frequent questions propounded to the medical witness in 
courts of law and it is not always an easy question to answer. The 
appearance of powder grains buried in the skin and the way in which 
they may have penetrated certain thicknesses of clothing will some- 
times indicate the approximate distance at which a pistol or other 
weapon was held when fired. Burning of the clothing, scorching of 
the skin, or singeing of the hair, which is apt to occur with the use of the 
old black powder, furnished invariable evidence of a shot at close 
range and it often indicates the manner in which the weapon was held 
when fired. Each weapon with a definite charge of the propellant has 
a distance limit where deposits of powder grains will make an im- 
pression upon the surface. The same may be said of the "powder 
brand " first described by Dr. B. F. N. Fish of Boston. * In experiments 
which he made on blotting paper with pistols he describes the powder 
brand as follows: "I noticed, in addition to the smutting of the 
paper by smoke and to the marks of the burned and unburned grains 
1 Dr. B. F. N. Fish, Boston Med. and Surg. Journal, Oct. 2, 1884. 



428 GUNSHOT WOUNDS 

of powder distributed around the bullet hole, one spot blacker and more 
burned than the rest. I found this was caused by the flame of the 
gases of the burning powder, and by the residue or ash of the burned 
powder striking and resting in this place. I also noticed that this 
burned and blackened spot held a most constant position, directly 
above, or above and a little to one side of the bullet hole/' He 
also found that the powder brand about the bullet hole invariably 
occurred on the hammer side of the weapon. That is, if the pistol or 
revolver was held hammer to the left, the powder brand occurred on 
the left of the orifice made by the bullet. When the weapon was held 
with the hammer to the right, the brand was noticed to the right of 
the bullet hole. When the weapon was held with the hammer up or 
down, the brand was located likewise above or below the bullet hole. 
The explanation of the position of the powder brand is as follows: As 
the weapon, a pistol or revolver, is held in the hand the latter forms 
the point of support for the recoil. The point of support is below 
the line of application of the force generated by the ignited powder and 
on discharge the force tends to make the weapon revolve about the 
point of support. The projectile is first discharged and as the weapon 
revolves upward the gases behind the ball follow the new direction 
assumed by the barrel, and the products of combustion are thus 
delivered on the target above the bullet hole, to one side, or below 
according to the way in which the hammer is held. If the weapon is 
held stationary in a vice when fired, the recoil does not affect the direc- 
tion of the barrel and the brand and tattooing are equally distributed 
about the bullet hole. When held normally in the hand the distance 
of the brand from the bullet hole is greater as the distance between the 
weapon and target increases: the angle made by the barrel in its align- 
ment before and after the recoil is the same, but the line on the target 
which subtends this angle will naturally increase with the distance 
from the point of discharge. 

The appearance of the powder brand has frequently figured in 
the courts. 1 When present, it has afforded strong presumptive evi- 
dence of suicide or homicide. 

The powder brand as described is better marked with the use of the 
old black powder in pistols and revolvers. We have found that the 
greater number of powder marks, independently of the brand, was in- 
variably on the hammer side of the weapon. This was the case with 

1 Text-book of Legal Medicine, etc., Peterson and Haines, article on Gunshot 
Wounds by Dr. J. N. Hall, W. B. Saunders Co., Phil., 1903. 



MEDICO-LEGAL PHASES OF GUNSHOT WOUNDS 429 

all the specimens tested with the exception of the Peyton powder when 
shot out of the military rifle. With this the majority of the powder 
grains appeared below the bullet hole when the rifle was held in the 
regular way. It is possible that other brands of powder will act 
likewise, hence the necessity of conducting tests in any given case. 

Witnesses in courts of law often need to know the behavior of the 
different explosives relating to the degree of powder burn or tattoo as 
modified by the distance of the object, the size of bore and length of 
barrel, the amount and standard of powder, etc. The exhaustive 
experiments which we made in 1895 may be of assistance to future 
experimenters or to those who have occasion to seek information as 
witnesses. In these experiments we tested the effects of the more 
common rifles and revolvers used in this country, from which we 
fired nearly all the brands of black and smokeless powders in the 
market at that time. 1 Not infrequently the weapon is pressed 
against the surface and held tightly by the suicide so that the gases 
and the unconsurned particles from the propellant are driven into the 
wound, and the skin about the wound of entrance will give no evidence 
of either brand or tattoo. Unless the wound is carefully examined 
the proximity of the weapon at the time may be overlooked. The 
wound in such a case would have the appearance of one having been 
inflicted at some distance. In the case of Normal Harris, which was 
noted by Dr. C. S. White of Washington, the suicide held the 
.38-caliber pistol against the scalp behind the right ear and fired. 
There was no scorching of hair or skin and no evidence of marks like 
tattooing left by the powder on the scalp. The suicide was found 
dead in an alley with a bullet hole in his head and, to add to the 
complication in the case, the weapon with which he had inflicted the 
wound had been taken by someone who happened to be passing by. 
A careful examination of the wound proper revealed particles of the 
propellant and gave positive evidence of a shot delivered at close 
contact. 

The distance from the weapon can sometimes be determined ap- 
proximately by the amount of penetration of the projectile. As a 
rule the penetration is in proportion to the velocity. Close shots 
penetrate farther because the bullets have a maximum velocity. 
Formerly shots from pistols and revolvers seldom emerged from the 
body when they happened to collide with resistant bones. Because 

1 Experiments Illustrating the Degree of Powder Burn, etc., Journal Assn. 
Mil. Surgeons, Vol. V, 1895, p. 212. 



430 GUNSHOT WOUNDS 

of the more modern types of revolvers and the automatic pistols 
employing steel-jacketed bullets which have come into use, with an 
initial velocity as high as 1400 f.s., the penetration of projectiles for 
these weapons has been correspondingly increased. 

A lead bullet possessed with maximum velocity will at times 
fail to penetrate as far as it does when animated by a lower velocity. 
Experimenters often notice, for instance, that a .38-caliber Colt's 
revolver bullet will perforate the skull of a cadaver at 25 feet, when it 
will fail to do so at contact or a foot or two away. The explanation 
given is this: a lead bullet traveling at a maximum velocity makes 
such a sudden and violent impact that bone particles have not time 
to separate or give way to enable the ball to pass. The momentary 
resistance is such that the bullet flattens, hence the deformation 
which adds to the sectional area of the bullet, and to this deformation 
we ascribe the loss in penetration. This point came up recently, in 
the case of a young officer of one of our services, when the government 
sought to show that the officer came to his death by suicide by shooting 
when he lay on the ground in a struggle with other officers, who were 
endeavoring to restrain him. The muzzle of a .38-caliber new service 
Colt's revolver was held against the right side of the head and fired. 
The ball entered the skull and was lodged in the brain substance on the 
opposite side more or less deformed. The prosecution maintained that 
the pistol discharged at such close range should have sent the ball 
through the head and that in all probability the pistol was discharged 
at some distance by someone else. There were eye witnesses to the 
occurrence, and other evidence to confirm the charge of suicide. The 
experts consulted in the case held to the opinion that the failure of the 
ball to make a complete perforation at such a proximal range was due 
to loss of penetration by deformation of the bullet at the time of 
impact. See also case of Sergt. V., Figs. 107 and 108, page 187. 

Wounds from Shotguns. — The penetration of pellets from shotguns 
varies naturally with the amount and kind of charge, the distance of 
the weapon and the age of the explosives. In cases where the court 
desires information on the degree of penetration of lead pellets or 
projectiles fired from any weapon, experiments to simulate the con- 
ditions at the time of occurrence in a given case should be resorted to, 
either on cadavers or other materials. 

Wads and wadding from shotguns and pistols depending on the 
compact nature of the materials from which they are made have 
caused fatal results at close quarters and the charge of powder alone 



MEDICO-LEGAL PHASES OF GUNSHOT WOUNDS 431 

from any weapon is at times sufficient to cause death when discharged 
nearby. 

Projectiles from shotguns may be fine or coarse shot, slugs, pieces 
of metal of any kind, pebbles or a ball. Unless the latter is used the 
effectiveness of the weapon hardly exceeds 100 yards, although 
instances of death beyond this distance from stray pellets are recorded. 
The caliber of shotguns varies approximately between .424 inch to 
1.052 inches. The charge of shot makes a close target in accordance 
with the degree of " choke." When the choke is absent the tendency 
to spread is markedly shown. The charge has a single point of 
entrance at from 1 to 2 feet depending upon the kind of weapon and 
the manner of loading. The wound of entrance when the charge takes 
effect en masse is never so regular as it appears in the case of a bullet. 
Separate shot holes appear as the distance increases. The pellets 
diverge on entering, as a rule, and this is especially true if a bone is hit. 
An X-ray of the surrounding parts will generally indicate the amount 
of spreading. The paper-shot shell has been known to separate from 
its metallic head and deliver a wound in a single load as far as 200 
yards. 

Evidence of Proximity Afforded by Clothing. — Perforation of the 
clothing from a projectile takes place very much in the way that the 
skin is perforated. The hole entering the dress is round if the velocity 
of the bullet is high. A lower-velocity bullet pushes the clothing 
forward in the shape of a cone, the apex of which is perforated in the 
form of a slit or triangular tear. After the perforation has taken 
place the clothing assumes its original position or part of it may hang in 
the wound. The bullet hole is small in proportion to the elasticity 
of the stuff penetrated. Clothing that is stretched over the body at 
the time of perforation shows a hole approaching the size of the 
bullet. Powder burn or stain may occur from close shots. The zone 
of burning is round or oval as the shot is delivered perpendicularly 
or at a tangent to the cloth. Unburned powder grains can be picked 
out of the cloth and with the aid of a magnifying-glass Doctor J. 
N. Hall, of Denver, Colorado, was able to prove in a recent court case 
that the shooting took place 2 or 3 feet from the muzzle by demon- 
strating isolated patches of burned fabric due to ignited grains when 
the distance had been too great to cause burning by the flame. 

3. When was the Wound Inflicted, Before or After Death? — 
This question is important, and it is often asked to arrive at the length 
of time the wounded person may have survived after receiving a mortal 



432 GUNSHOT WOUNDS 

wound. This can only be arrived at by the appearance of inflamma- 
tion in life, which does not set in with anything like distinguishing 
features until the lapse of ten to twelve hours in tissues generally, 
although we know that plastic lymph is thrown out in a wound of the 
peritoneum in about three hours. The question of the wound having 
been inflicted before or after death is not easy to answer unless the 
missile has injured a vessel with resulting hemorrhage and the forma- 
tion of coagula. Gunshot injury in dead tissue is not followed by 
hemorrhage unless the projectile happens to wound a large blood- 
vessel and preferably a vein. Evidence of the movements the wounded 
may have made after receiving the injury will sometimes throw light 
on the subject. 

In a case where several wounds may be found on a dead body it is 
sometimes pertinent to know which of the wounds caused death. The 
question can only be answered on general principles, taking into con- 
sideration the nature of the wound, the parts injured, the amount of 
injury to vital organs, etc. In a street encounter in one of our South- 
ern cities recently a man of prominence was shot with an automatic 
pistol several times in quick succession through the body. Eye 
witnesses saw the wounded drop lifeless to the ground very suddenly 
during the scuffle that was going on. The post-mortem revealed several 
wounds capable of causing death. In one of these the ball severed 
the medulla oblongata. The medical witnesses testified that this 
wound had caused immediate death, and that it was received when the 
wounded was noticed to drop lifeless to the ground. 

4. Is the Wound Dangerous to Life? — The danger to life is de- 
pendent upon the anatomical regions traversed, the local and general 
resistance, and the complications that are apt to set in. The danger 
in gunshot wounds has been lessened very much in recent years 
because of the change in firearms and in the projectiles they employ, 
and also because of the great advances in wound treatment. This 
beneficence has come largely from the reduction of the caliber and 
weight of the bullet but more especially from encasing the projectile 
in a steel jacket. The enveloped types of bullets do not disinte- 
grate as the lead bullets did, their hard exterior prevents deformations 
that were once common and which added to the gravity of wounds. 
The small frontage of the rifle bullets ranging from .256 to .30 
calibers adds to the humane features of the injuries in the soft 
parts, the epiphyseal ends of bones, the lungs and liver. Gunshot 
wounds of the abdomen in war that were uniformly fatal with the 



MEDICO-LEGAL PHASES OF GUNSHOT WOUNDS 433 

old armament have given under modern conditions a hope of recovery 
in 25 per cent, of the cases without operation in wounds inflicted by 
the ogival-headed reduced-caliber bullet. But the recent change in the 
shape of the reduced-caliber military rifle bullet from an ogival head to a 
pointed bullet has again added very much to the fatality of all body 
wounds and abdominal wounds especially. This bullet, as already 
stated when discussing the characteristic features of gunshot wounds 
in Chapter II, has no stability. It turns on encountering the least 
resistance and when it does so while traveling with a rapid mo- 
mentum its rending effects are terrific. The Turks used this bullet 
in the recent Turko-Balkan War with deadly effect; but few abdominal 
wounds lived to reach hospital care. The deadly slashing effect of 
this bullet has made it popular with sportsmen and it will no doubt 
be very much used in the hunt for large game. 

Gunshot wounds of the abdomen in civil practice by the pro- 
jectiles of pistols and revolvers, once so fatal, now give about 50 per 
cent, of recoveries under modern methods of treatment. When the 
wound is inflicted by the smaller calibers the death rate is much less. 

Notwithstanding the beneficence which has resulted from the 
change in firearms and modern treatment, a perforating gunshot 
wound of the abdomen from any weapon should at all times be con- 
sidered dangerous to life. The same may be said of gunshot wounds 
of the lungs. It may be stated as a broad principle that gunshot 
wounds are dangerous to life in proportion to the amount of tissue 
involvement. This is also true of wounds from weapons that appear 
to be attended with little danger like toy-pistol wounds. Wounds 
of this class have been described under toy-pistol tetanus and they owe 
their dangerous nature to the liability to infection from virulent 
microorganisms like the bacillus of tetanus in wounds that are marked 
by the presence of laceration and hsematoma. 

Gunshot wounds as a class are more or less contused and lacerated, 
and because of this fact their gravity never can be overlooked. The 
surgeon will have to form his estimate of the amount of danger in a 
given case by his knowledge of regional anatomy and the importance 
that the tissues traversed may bear to life, directly or indirectly. The 
subject of wound infection plays a great role in danger to life. To 
appreciate this properly anyone who expects to testify in a given case 
should read carefully the chapter on Infection of Gunshot Wounds. 

5. The Practitioner's Liability in Case of Infection. — The knowl- 
edge of antisepsis and the value of cleanliness are becoming so well 

28 



434 GUNSHOT WOUNDS 

known to the laity that criminal negligence with sepsis resulting has 
already figured in the courts. Incidentally the subject brings up the 
medico-legal phase of septic bullets. There are two aspects of the 
practitioner's liability; he may be prosecuted criminally for negligence 
producing death, or he may be asked civilly to respond in damages 
by the party injured or by his heirs. For our purpose, however, the 
rules of evidence and the burden of proof may be treated as sub- 
stantially the same. Speaking thus with approximate accuracy, if 
the plaintiff or the prosecution establishes (1) the existence of blood 
poisoning; (2) surgical uncleanliness in the use of the instruments or 
dressings ; (3) failure on the part of the operator to render his hands or 
those of his assistants and the field of operation aseptic in the ordinary 
way, a prima facie case is made against the surgeon which he must 
overcome. Such culpable negligence in the light of our present 
knowledge is considered unpardonable and yet in the case of a gunshot 
wound it would be difficult to say that sepsis had resulted from neglect 
alone or that a deadly poison like that of tetanus had resulted from said 
neglect and not as a result of a bullet infected with tetanus spores. 
Ordinarily the plaintiff might avail himself of evidence that (1) the 
patient's clothing, pierced by a bullet, was old and dirty, and hence 
probably not aseptic, and (2) that the skin at the wound of entrance 
and exit bore specific germs. Furthermore two additional lines of 
defence are open to him, viz., (1) the bullet itself might have been 
septic when fired, and (2) by ricochet, or otherwise while in transit, 
it might have become septic — two conditions either of which is well 
within the bounds of possibility. We have shown already by numerous 
experiments on animals shot into with septic bullets from many dif- 
ferent kinds of weapons, and at ranges up to 500 yards with the military 
rifle, that a septic bullet is not rendered sterile by the act of firing, and 
that it can become infected in ricochet. 1 

6. How Was the Wound Inflicted? — This question refers to the 
position of the individual when shot, (a) Was he standing or lying 
down? (b) Was he running from his assailant or advancing? (c) In 
what direction was the weapon pointed when fired? (d) Was it 
fired from the shoulder or hand? 

The above queries can all be established by eye witnesses. In the 
absence of such testimony we have to depend on such evidence as 

1 Are Projectiles from Portable Hand Weapons Sterilized by the Act of Firing? 
Can a Septic Bullet Infect a Gunshot Wound? By Louis A. LaGarde, U. S. A. 
Proceedings Pan-American Congress, Vol. I, 1893. 



MEDICO-LEGAL PHASES OF GUNSHOT WOUNDS 435 

may be afforded by the distinction of the wound of entrance from the 
wound of exit. In those cases where the distinction is well established 
the position of the victim when shot will be apparent. It will show 
whether the wound was received when facing the muzzle or whether 
his side or back was nearest the weapon. The track of the bullet 
from the point of entrance to the point of exit or lodgment is usually 
a straight line. When it is, we here have evidence to show how the 
weapon was pointed when fired. When a line between the two 
wounds or the wound of entrance to the point of lodgment is curved 
from a deflected bullet the value of the evidence bearing on the way in 
which the gun was pointed is doubtful. In former times such cases 
were frequent. The velocity of the projectiles was lower and they 
were easily deflected from their course before and after striking the 
body. Many cases are cited in the literature of gunshot wounds 
where bullets after entering the skin described a circuitous course 
through the subcutaneous tissues half-way around the body. In 
such cases the wounds of entrance and exit indicated a direct course 
when in reality, as determined by autopsy or otherwise, the ball had 
been deflected. 

7. Was it Accident, Suicide or Homicide? — This question often 
comes up in cases of death from gunshot injury. An attempt at 
suicide shows a wound directed against a vital part, as a rule; the wound 
is not located on the back part of the body. A suicide often selects 
the inside of the mouth to reach the vital part of the brain, a location 
that could not be selected by a murderer, except on helpless individ- 
uals. In 368 suicides by firearms in France 297 were from wounds 
in the head; of these 234 were fired into the mouth, only seventy-one 
were from wounds inflicted on the chest or abdomen (Reese). The 
other favorite location selected is the temple and the right temple is 
chosen in the vast majority of the cases. Suicidal shots, as a rule, are 
delivered at close range, they generally show powder marks, the pene- 
tration and distribution of which should be carefully studied to 
ascertain the distance from the muzzle and the way in which the 
weapon was held. Here we refer to the powder brand and other 
evidence from the explosive which has figured so often in the courts 
and which we have already explained at length. With reference to 
the value of powder brand in cases of suicide, if one will take an 
unloaded revolver or pistol in his right or left hand and go through 
the execution which a suicide must follow to shoot himself he will 
at once learn the limited amount of motion that one commands in 



436 GUNSHOT WOUNDS 

directing the hammer to the right or left. The limit of movement 
when aiming at a target corresponds to the amount of pronation and 
supination of the wrist, and the area occupied by the different pow- 
der brands on blotting paper is about equal to a semicircle. A 
powder brand outside this semicirlce should favor the theory of 
homicide. 

In an attempt at suicide there is usually evidence of design which 
is not shown in cases of accident. In the matter of design suicides 
have used strange weapons. Many unusual devices which bear 
evidence of the expenditure of time and thought have been employed. 
Aside from the ordinary weapons like pistols, rifles, and shotguns, 
they have been known to extemporize fowling-pieces out of iron 
piping, large hollow keys, toy cannons and bottles charged with 
explosives and sand, or gravel, nails, pieces of lead; and liquids like 
water, petroleum and rum have been used to take the place of 
ordinary projectiles. In summing up the evidence in a given case, 
one should not lose sight of the fact that design can be planned by a 
murderer in an effort to conceal crime. The shotgun or rifle is not so 
often employed by suicides, but when used there is usually evidence 
of design. In the case of a prominent jurist personally known to the 
writer a shotgun was used. A string about 2 feet long was tied by 
its middle to one of the triggers. A loop to admit the big toe was 
provided in each end of the string. He then sat on the edge of his 
bed and placing the muzzle of the weapon in his mouth, the gun was 
discharged by pressing the toes, which had been previously placed in 
the loops, toward the floor. 

The question of suicidal or self-inflicted accidental wounds often 
figure in the courts with a bearing on insurance. Wounds from both 
causes will have the characters of near wounds. When the body or 
premises have not been disturbed, the relative position of the body 
and weapon will give evidence of the presence or absence of design 
in the majority of cases. 

When the weapon is still firmly grasped in the hand it is proof 
positive that the wound was self-inflicted, but it affords no bearing on 
whether the wound was suicidal or accidental. The facts in such a 
case must come from other evidence. 

When a wound is inflicted by accident on a second person, it is 
difficult without direct evidence to say whether it was accidental or 
homicidal. In such cases the lesion with reference to wound of en- 
trance and exit, and the direction of the channel made by the ball 



MEDICO-LEGAL PHASES OF GUNSHOT WOUNDS 437 

should be carefully compared with the statement of the person who did 
the shooting. 

With old firearms, when loading was done by hand, wadding from 
paper and other material found in a wound has often served to establish 
the guilt of the offender. Thus, hand-writing on paper or print from 
paper wadding, has been found in some cases to have been torn from 
remaining particles in the possession of the person who had com- 
mitted the crime. Evidence from such a source is rare now because 
nearly all ammunition is loaded by machinery. Still the projectile, 
wadding if any, and even particles of the explosive should be carefully 
preserved and turned over to competent authority for future study. 

Chemical analysis of bullets was resorted to formerly to determine 
guilt or innocence. Lead bullets are now hardened with antimony and 
small shot contains arsenic. Old fashioned missiles of this class were 
composed entirely of lead. Lead slugs with neither antimony nor 
arsenic are occasionally used in shotguns. Thus in a case cited a 
number of deformed shot approaching the appearance of slugs were 
removed from a dead body. They contained arsenic, but slugs found 
in the prisoner's possession were arsenic-free. 

Since the weight of the bullet at times enters into a case, it is always 
well to take the weight of all missiles extracted for future comparison. 

8. Identity of the Individual by the Flash of the Firearm. — With 
the use of black gun powder there is ignition and the flash from 
shotguns, revolvers and pistols containing a sufficient charge will 
illuminate the vicinity of the shooting in a dark room enough to iden- 
tify the features of an individual as far as 5 meters when the observer 
is placed laterally to the one doing the shooting; and when viewed 
while facing the one shooting, the latter can be recognized as far as 
10 meters. 1 The test is different with the so-called smokeless powders. 
With them there is no flash at the time of discharge because there is 
no ignition or fire. Experiments with black powder and the various 
brands of smokeless powder when fired into blotting paper will con- 
vince anyone of the truth of this statement. We have shot rifles, 
pistols and revolvers loaded with smokeless powder in a basement 
when the space was absolutely dark, with negative results in all 
instances. 

9. Self-inflicted Non-fatal Wounds. — Self-inflicted wounds are 
at times made to avoid military service, to elicit money or charity, 
or to impute murder. Again a man making a futile attempt at 

1 Dr. Romary, Arch. d'Anth. Crim., 1908. 



438 GUNSHOT WOUNDS 

suicide will often endeavor to conceal his act, and ascribe the wound to 
the hand of an assassin. Examination of such wounds will show that 
with the exception of attempted suicide they will not be directed 
against vital parts. The skin will show laceration, ecchymosis, smut, 
burn or tattoo from gun powder. Marks of the powder may be on 
the hand holding the weapon, as so often happens in self-inflicted 
wounds. The powder brand when present will indicate how the 
weapon was held with reference to the direction of the hammer. 

10. At What Time Was the Firearm Discharged? — This resolves 
itself into a very important question in many cases because its solution 
may serve to identify the weapon. If black powder was used K 2 S 
will be found in the barrel shortly after discharge. Later oxidation 
produces K 2 S0 4 . Experiments under the condition of moisture and 
temperature prevailing at the time of discharge should give the time 
approximately. The author is not acquainted with any method 
which will fix the time if smokeless powder has been used. 

11. Was the Projectile Jacketed or Not? — The effects of armored 
bullets have shown such distinguishing characteristics on bone when 
compared to the lesion inflicted by the ordinary lead bullet, as shown 
by dissection and the appearance outlined on an X-ray plate, that 
they deserve special mention at this time. The use of jacketed bullets 
is becoming more and more popular with the manufacture of pistols. 
The question of the kind of weapon, as well as the kind of bullet, 
whether jacketed or not, can be established by strong presumptive 
evidence from the presence or absence of lead particles on the X-ray 
plate. A lead bullet fired from an ordinary revolver at moderate 
velocity leaves particles of lead in the osseous lesions and their vicinity, 
in nearly every instance; and the reverse is true if the lesion has been 
inflicted by an automatic pistol carrying a jacketed bullet. The 
osseous lesion in the case of the latter is, as a rule, remarkably free 
from metallic particles unless the nose of the bullet has been marred 
by filing, etc. Military surgeons in the wars of the present distin- 
guish at a glance on an X-ray plate wounds from shrapnel balls which 
are always made of lead from those inflicted by the mantle pro- 
jectiles of the reduced-caliber rifle. In the former, in the osseous 
lesion and the soft tissues beyond the point of impact in the bone one 
will find deposits of small fragments of lead distributed in a stream-like 
manner. The bone lesion from the jacketed bullet is usually free from 
metallic particles unless there has been separation of the jacket from 
the lead core. Such fragmentation will sometimes take place when the 



MEDICO-LEGAL PHASES OF GUNSHOT WOUNDS 439 

jacketed bullet makes an irregular impact against the bone or when 
its jacket has been impaired by ricochet or otherwise. If the plate 
should show absence of lead particle, the use of a jacketed bullet is 
indicated and since the latter are only used in pistols of the automatic 
class and not in revolvers, the kind of weapon also becomes apparent. 
A study of figures representing X-ray lesions in bone in other chapters 
will show the differences referred to. 

In any case that is likely to go before the courts, the examiners 
should take careful notes at the time of the first examination, and 
preserve these for future reference. The exact location of the en- 
trance and exit wounds, if the latter is present, should be noted. The 
character of the wounds, their size and shape, their condition as to 
laceration, the character and amount of hemorrhage and evidence as 
to powder brand and tattooing will be important points to note. 
When a post-mortem is held, minute notes should be taken of the find- 
ings, and filed. The condition of the weapon, its location when 
found, the presence or absence of smut in the barrel should also be 
noted. 

In the foregoing medico-legal phases of gunshot wounds we have 
endeavored to consider the majority of the questions that are likely 
to come up in courts of law. There are doubtless many more that 
writers on the subject cannot foretell. Thus the dangers from 
certain body wounds and the complications likely to set in cannot 
be dealt with at length in this chapter. They can only be grasped by 
a careful study of the chapters devoted to these subjects. For further 
particulars on the various kinds of explosives, firearms, projectiles and 
the characteristic features of gunshot wounds by different weapons the 
reader is referred to Chapters I and II. 



CHAPTER XV 
Field X-ray Apparatus 

The importance of radiography in dealing with military surgical 
cases in war has long been recognized, and many different types of 
apparatus have been devised for doing radiography under the condi- 
tions of active service. Up to the present time, however, no apparatus 
has been free from some one or more serious defect. The essential 
features of a field X-ray apparatus are sufficient power for good radi- 
ography and at the same time portability, compactness, and durability. 

The use of galvanic cells in connection with a coil was one of the 
first types suggested for field apparatus. It is a laboratory possibility 
to illuminate a Crooke's tube by a series of galvanic cells, but, owing 
to the small current produced, the quantity and quality of the radia- 
tions are unsatisfactory. 

Static machines were designed but were abandoned on account of 
numerous difficulties attending their operation. They were too 
cumbersome, too fragile, and extremely unreliable. Hand power 
applied to a static machine is a poor method of operating the machine, 
so that an engine must be provided for uniform high speed. If an 
engine were available, however, it would be better to employ it with a 
coil-dynamo apparatus which is of greater radiographic efficiency. 

During the Boer War, accumulators were frequently used with 
coils by English medical officers, and appear to have given satisfaction. 
There are two objections to the use of accumulators that prevent their 
adoption for field service. Their weight is excessive, but this is not so 
objectionable as the fact that they require an electrical supply to 
recharge them. If no means of recharging the apparatus be available, 
it is worthless in that locality. The recharging of accumulators 
requires a direct current, but an alternating current can be used after 
passing it through a rectifier. The absence of this rectifier, however, 
would preclude recharging. Accumulators may at times be employed 
for field X-ray work, but the ideal apparatus for this purpose must be 
self-contained and operable at any time and under all circumstances. 

Among the early forms of apparatus were coil-dynamo machines 

440 



FIELD X-RAY APPARATUS 441 

operated by man or horse-power, a revolving shaft transmitting the 
power to the dynamo. A tandem bicycle was also used, being con- 
structed so that it could be connected to a dynamo by a chain drive. 
These methods were never found satisfactory, as sufficient power 
could not be generated. Later a gasoline engine was employed to 
furnish the power and was found practical. 

The coil-dynamo machine operated by a gasoline engine is one of 
the best types of field X-ray apparatus and the medical departments 
of most armies have adopted it. Difficulties that have attended the 
operation of this apparatus, in most instances, have been with the 
engine. . No gasoline engine has been found that has given perfect 
satisfaction when operated in connection with a coil apparatus. The 
difficulties have chiefly been with vibration and in an annoying varia- 
tion in the speed of the engine when the current is switched on and 
off the coil. Small, one-cylinder marine engines of H to 3 H.P. 
acquire a marked vibration when running at full speed and must be 
anchored securely to a base. This vibration is reduced in a two- 
cylinder engine which weighs only slightly more, runs much better, 
and is altogether more satisfactory. The variation in the speed of the 
engine is due to the peculiar conditions attending the operation of a 
coil. Ordinarily a gasoline engine runs under a uniform load through- 
out its operation, but with a coil it is subjected to a sudden change 
from no load to full load and vice versa. When the current from the 
generator is switched into the coil, the engine drops slowly in speed 
and the voltmeter will show a corresponding fall. Opening up the 
throttle to a greater degree will slightly counteract this retardation. 
Upon throwing off the coil switch which removes. the load from the 
engine, there is a sudden acceleration in its speed, and the throttle 
should be adjusted accordingly. This action is much less marked 
in a two-cylinder engine of 4 to 6 H.P. operating a 2-K.W. generator. 

The ignition devices on gasoline engines for field X-ray apparatus 
are important and require some consideration in their selection. A 
good reliable high-tension magneto should be used. The use of dry- 
cell batteries to initiate the current necessary for the spark plug is 
objectionable. They become exhausted in time and must be replaced 
by new ones. This may occur in the field at times when no cells are 
procurable. 

Recently a 5-H.P. motor-cycle engine was used to operate an 
interrupterless apparatus constructed for field service. It was run 
at a speed of about 1200 R.P.M. This is much faster than a marine 



442 GUNSHOT WOUNDS 

engine and makes it possible to connect engine and generator by the 
same shaft. The engine worked satisfactorily but there was some 
difficulty in cranking. A spring cranking device has been used but 
with only small success. 

The desired current for a field X-ray machine is about 20 amperes 
at 110 volts which is furnished by a 2-K.W. generator. A generator 
of 2-K.W. capacity requiring a speed of 600 to 800 R.P.M. is too heavy 
for field use and selection must be made from the smaller types that 
deliver the same current at 1200 to 1800 R.P.M. This speed is in 
excess of that of the ordinary marine engine and consequently it is 
necessary to connect engine and generator by a chain drive for multi- 
plication. The high speed of the motor-cycle engine makes it possible 
to mount the generator and engine on the same shaft, and for this 
reason, together with its comparative light weight, it is a desirable 
engine for field apparatus. However, the excessive vibration of an 
engine which runs at this speed is a serious disadvantage. It must be 
overcome by means of one of the various forms of shock absorbers, else 
an outfit will soon shake itself to pieces. 

The best coil for general radiography is one of 10-12-inch sparking 
distance. This size is the one sold by most X-ray apparatus manu- 
facturers. It is not excessive in weight and is best suited to our 
purpose. 

Of the several types of interrupters now on the market, none have 
given as much satisfaction as the electrolytic. A mechanical in- 
terrupter would be an ideal apparatus provided a high speed of 
interruptions could be maintained without injury to its parts when 
working with strong currents. A simple mechanical interrupter of 
the App or vril type is not satisfactory when working with a 20- 
ampere current at 110 volts pressure, since the contact points become 
burned out and the apparatus ceases to work. Various mercury 
turbine interrupters have been tried but they are inferior to the 
electrolytic. The great objection to the electrolytic interrupter is 
the necessity of equipping the apparatus with a large amount of 
sulphuric acid, for there is always the risk that the glass bottles 
containing this acid will become broken in transportation and cause 
much damage. To offset this disadvantage it has been suggested that 
chromic acid be used instead of sulphuric. Chromic acid is crystal- 
line, can be readily handled, and in 1 to 10 aqueous solution works 
well. 

During the past year the Medical Department, U. S. Army, has 



FIELD X-RAY APPARATUS 443 

carried on a number of experiments with field X-ray outfits. Instead 
of using the induction coil, all the outfits are of the interrupterless 
type. They consist of a gasoline engine, 5 to 7 H.P., directly connected 
to drive a 2 K.W. A.C. generator. From the generator the current 
passes to a transformer where the voltage is stepped up to about 
100,000 volts. On the same shaft as the generator and engine is fixed 
a mechanical rectifier or commutator so adjusted that its poles convert 
the two pulsations of the A.C. coming from the transformer into a 
pulsating direct current which passes to the X-ray tube. The opera- 



Fig. 157. — Type of field X-ray apparatus with motor-cycle engine. 1, Engine; 2, motor; 3 
transformer; 4, box containing revolving rectifying switches; 5, cable containing wires for circuit 
from motor through primary of transformer and return; 6, secondary terminals of transformer; 
7, terminals through which current is carried from rectifying switches to the X-ray tube. 

tion of the engine and the control of the current is accomplished by a 
simple adjustment. Two types of engines have been used, a small 
two-cylinder, 6-H.P. marine engine, and a 7-H.P. motor-cycle engine. 
The former operates at a lower speed than the latter, and vibration is 
therefore not so marked. With each outfit excellent radiographic 
work has been done. Each outfit is complete in itself, being equipped 
with all the photographic supplies necessary. The outfits are so con- 
structed that they can be quickly and securely packed for transporta- 
tion, and the containers are so fashioned and so proportioned that 
they can be easily handled and packed in the ordinary army four- 
horse wagon. The specifications from the Surgeon-General's office 



444 



GUNSHOT WOUNDS 



limits the weight of the apparatus to 2000 pounds, and the maximum 
weight of the various units in which it is packed for transportation to 
400 pounds. This division of weight into several parts is an important 
factor in handling the apparatus, as each boxed unit can be readily 
carried by a squad of four men. 

Several outfits have been constructed and are now installed at 
post hospitals for further observation as to their durability and radio- 




Fig. 158. — Type of field X-ray apparatus with marine engine. 1, Engine; 2, motor; 3, trans- 
former; 4, rectifying switches; 5, cable containing wires for circuit from motor to primary of trans- 
former and return; 6, secondary terminals of transformer; 7, terminals through which current is car- 
ried from rectifying switches to X-ray tube; 8, X-ray tube; 9, packing box utilized as table; 10, 
plate holder. 



graphic efficiency. Three of these outfits are shown in Figs. 157, 158, 
159. They are in constant use and all defects in construction are being 
carefully recorded. It is hoped that in a short time sufficient informa- 
tion will have been obtained to enable the department to determine the 
most satisfactory engine for use with these outfits. Experiments 
thus far seem to indicate that the motor-cycle engine, while light and 
very powerful, is too complicated and delicate for use with these 
machines. It is believed that these experiments will show that a 



FIELD X-RAY APPARATUS 



445 



low-speed marine engine geared or belted to the generator will prove 
to be the most suitable motive power, these engines being simple in 
construction, easily operated under almost any conditions, having very 
few parts, and being much more durable than the complicated light- 
weight engine. As the X-ray outfits cannot, in the field, serve any 
purpose at the front — in fact, are not practical or needed further 
forward than the more or less stationary evacuation hospitals, the 
increased weight occasioned by using the slow-speed powerful engine 
is not a serious disadvantage. 




Fig. 159. — Latest type of field X-ray apparatus with marine engine. 1, Engine; 2, motor; 3, 
transformer; 4, revolving rectifying disc; 5, cables containing wires for circuit from motor through 
primary of transformer and return; 6, box containing X-ray tube mounted so as to slide on hori- 
zontal rods; 7, army stretcher; 8, canvas strip weighted at ends to hold plate in position. 

Tubes. — Each apparatus should be equipped with at least four 
6-inch or 7-inch tungsten target tubes. To prevent breakage in 
transportation these tubes must be securely packed. This is quite 
satisfactorily accomplished by having a special chest made up for the 
tubes with holders in which each tube can be placed, the chest and 
holders being thoroughly lined with very thick and soft padding 
materials. Breakage is certain to be a great factor in any scheme of 
packing tubes. If space is not a factor, tubes should be packed in 
excelsior and each tube inclosed in a separate box. 

Table. — For use with the portable apparatus described above, 



446 



GUNSHOT WOUNDS 



The Roentgen Mfg. Co. of Philadelphia has devised an excellent 
portable table which can be conveniently folded up for transportation. 
It is constructed so that an army stretcher forms the couch under 
which plays a tube supported in a suitable tube holder. The tube 
holder can be displaced along the length of the couch, while the litter 
can be moved laterally, the combination of movements making it 
possible to radiograph any part of a patient without disturbing him. 
The plate is held by a canvas strip weighted at both ends, so that when 
it is placed over the plate it holds it securely in position. With this 



L. GLASS SHIELD 



TUBE HOLDER 



W 




Z3 



TOP OF ONE OF THE 
PACKING BOXES PLACED 
ON ITSSIDF AND USED 
AS AN OPERATING TABLE. 



CROSS CONNECTION WITH A 
CLAMPING DEVICE TO FIX IT 
IN ANY POSITION ON VERTICAL 
ROD, AND A SECOND CLAMP TO 
FIX THE POSITION OF THE 
J"l HORIZONTAL ROD. 



© 



d. 



o 




HANDLE 



1 1 4 PIPE WHICH SLIDES THROUGH 
HORIZONTAL OPENING OF THE 
CROSS CONNECTION TO BE LON3 
ENOUGH TO SUPPORT THE TUBE 
OVER PISTAL EDGE OF TABLE. 

■2" PIPE 

ETAL COLLAR FASTENED IN 
UPPER SIDE OF BOX WITH AN 
OPENING THROUGH WHICH THE. 
VERTICAL ROD CAN BE PASSED. 



-VERTICAL ROD OF TUBE 
SUPPORTING DEVICE, THIS 
CAN BE SLIPPED INTO 
POSITION WHEN BOX IS 
PLACED ON rTS STDE. 



/5 



ETAL PIECE FASTENED IN 
LOWER SIDE OF BOX WITH AN 
OPENING TO RECEIVE AND 
SECURELY FASTEN FOOT 
OF VERTICAL ROD SO IT CAN 
NOT TURN OR SLIP OUT. 



Fig. 160. 



form of table excellent radiographic work can be done. However, it 
is believed more satisfactory radiographs can be made if the tube is 
supported above the patient. In addition it does not seem necessary 
to increase the weight of an outfit with a special operating table, when 
the apparatus must be packed in a number of large boxes one or more 
of which can be utilized as a table. Means can easily be provided for 
supporting an adjustable tube holder above one of the boxes. Fig. 160 
shows a rough sketch of a table of this kind, one of which has been 
made up by the Waite & Bartlett Co. of New York City in connec- 



FIELD X-KAY APPARATUS 447 

tion with a field X-ray apparatus built by this company, and it has 
proven entirely satisfactory. 

Dark Room. — The Surgeon-General's office has had several 
portable cabinets constructed, all of which have for a time proven 
satisfactory. But these cabinets are not durable and under the rough 
usage incident to field service the materials of which they are con- 
structed cannot be depended upon to provide a light-proof compart- 
ment. Pending further developments in the line of portable dark room 
it seems that in the field some of the numerous forms of developing 
tanks must be used for developing X-ray plates. These tanks give 
good results and while their product may not be equal to that which 
can be obtained in a well-equipped dark room, yet the plates produced 
furnish all the information ordinarily required under field conditions. 

The accessories required for a complete field apparatus are a supply 
of X-ray plates, fluoroscope, lenticular stereoscope, chemicals for 
development and printing, trays, printing paper and frames, orange 
and black envelopes for the protection of plates, graduates, tool kit 
and important spare parts for the engine, and a tank for gasoline. 

A field X-ray apparatus in order to be portable must either be 
mounted on an automobile or wagon bed or divided into several parts 
which can be boxed. The French Army has constructed an X-ray 
automobile, which is said to be very satisfactory. Its engine provides 
power for the operation of the apparatus. The German Army uses a 
wagon and their apparatus is one of the best for field service. The 
apparatus used by the United States Army is contained in several 
boxes which can easily be loaded into an escort wagon. The last 
method appears to be practical and reliable. Disabling accidents are 
liable to happen either to an automobile or wagon, especially the 
former, so that the construction of an X-ray apparatus permanently 
upon either does not appear to be as good as separate boxing. The last 
method is certainly best adapted for boat and railroad transportation. 

In regard to the proper points at which field X-ray apparatus should 
be operated when an army is in active service, it is the general opinion 
that they are not required further forward than the stationary hospitals 
along the lines of communication. They should not be a part of the 
equipment of a field hospital. According to the present organization 
of our medical department, field hospitals are daily evacuated 
to the stationary hospitals, and all cases that require skiagraphy 
can safely stand the delay of a day or two incident to their arrival 
at the hospitals in the rear. The presence of an X-ray apparatus at 



448 GUNSHOT WOUNDS 

a field hospital would tend to foster unnecessary surgical interference 
and add greatly to the work at that point. The large military hospitals 
at the base will be equipped with permanent X-ray apparatus, but 
it is probable that, at the beginning of a campaign, it will there be 
necessary to use portable outfits while awaiting the installation of 
other apparatus. In this connection it is to be stated that there 
is some difficulty attending the initial installation of permanent coils 
and other X-ray apparatus, owing to variations in local electrical 
currents. If the character of the electrical supply for a particular 
place be known, the supply department can provide an apparatus 
constructed for that current. In supplying an X-ray apparatus for 
a certain place it is necessary to know the character of the current, 
whether direct or alternating; the voltage; and, if the current be alter- 
nating, its cycle and phase. 

The construction of portable field X-ray apparatus has not yet 
reached perfection but every endeavor is being made by the Surgeon- 
General's office to secure an apparatus that will warrant its use at army 
posts during times of peace, so that medical officers will become 
familiar with the operation of the apparatus and there will be a large 
supply of field outfits available at once for service during active 
warfare. 



INDEX 



Abdomen, contusions of, 245 
wounds of, 245 

of adrenal gland, 295 

changes in the lesions of and the 
reasons therefor, 262 

classification, 245 

considered from standpoint of 
military and civil practice, 262 

contra-indications to operation, 
281 

facts to be remembered in the 
presence of, 257 

from the Spanish-American War, 
263 

of kidney, 293 

of large intestine, 287 

of liver and gall-bladder, 288 

non-penetrating, 248 

of pancreas, 291 

penetrating, 249 

perforating, 255 

positive signs of intestinal perfora- 
tion in, 259 

prognosis and fatality of, 260 

sigmoid flexure and rectum, 287 

small intestine, 283 

spleen, 292 

steps to be observed during opera- 
tion, 283 

stomach, 286 

treatment in military and civil 
practice, 262 

urinary bladder, 295 

value of early operation in, dis- 
cussed by a Congress of German 
Surgeons at Brussels, 1915, 274 
Abscess of brain, 192 
Air resistance on projectiles, 25 



Ammunition of 1906 for U. S. rifle » 
8, 32 
blank, 15 

supply for field guns, 16 
Anaerobes, virulence of, in war wounds, 

124 
Aneurysm, arterio-venous, 308 
traumatic, 302 
treatment of, by surgeons in present 

European War, 306 
varicose, 310 
Aneurysmal varix, 309 
Ankle, wounds of, 360 
Anthrax, bullets, 135 
Antiseptics, use of, in present European 

War, 145 
Automatic pistol, Colt's, 10 
pistols, Table No. 3, 72, 73 
rifle, 33 



B 



Bacillus Aerogenes Capsulatus in gun- 
shot wounds, 128 
malignant edema in war wounds, 127 
tetani in war wounds, 124 
Bacteriology of gunshot wounds, 123 
Ballistics, 24 

of pistols and revolvers, Table No. 3, 
72, 73 
Bergmann, Von, antiseptics in military 

surgery, 354 
Bier on the value of vessel suture as 

compared to ligation, 312 

Benet-Mercie system of machine gun, 3 

Bladder, urinary, wounds of, 295 

Blood-vessels, contusion of arteries, 301 

injury to, by reduced caliber bullets, 55 

partial and complete division of, 302 

traumatic aneurysm of arteries, 302 



29 



449 



450 



INDEX 



Bombs, 19 

Bone, injury to, by reduced caliber 
bullets, 55 

Bones, contusions of, 365 

Borden, Col. W. C, U. S. Army, on 
frequency of spinal injuries in 
modern wars, 215 

Bornhaupt, abdominal wounds by the 
Japanese bullet in Manchurian 
campaign, 265 

Bouvier and Chandrelier, on laparotomy 
in present European War, 275 

Brain, injury to, in g. s. fracture of 
skull, 168 

Breech-loading rifles, 6 

Bullet, the French, English and German 
compared, 33 
"S," "Spitz," or "pointed bullet, 

wounds by, 57 
dumdum, controversy concerning 
use of, in European War, 63 

Bullets from pistols and revolvers, with 
truncated cone, spherical seg- 
ment, soft-nose, blunt point, 
man-stopper, and their effects on 
dead and living tissues experi- 
mentally considered, 69 



Cadavers, value of experimental evi- 
dence by firing into, as compared 
to the evidence in the living, 42 

Canister, 16 

Cannon, hand, 3 

Carbine, 10 

Carrel, Alexis, on the use of a modified 
"Eusol" and "Eupad," 148 

Case-shot, 16 

Casualties in battle, 407 

in present European War, 419 

Chandrelier and Bouvier on laparotomy 
in present European War, 275 

Chest, gunshot wounds of, 228, 241 
hemothorax, common and severe in 
European War, 235 
treatment of, by John Rose Brad- 
ford and Captain T. R. Elliott, 
R. A. M. C, 235 



Chest, lodgment of bullets in, 242 
non-penetrating wounds of, 228 
penetrating wounds of, 216 
treatment of, 234 

wounds by the new armament in 
Santiago campaign, 228 
by the old armament, 228 
certain symptoms and complications 

of, 232 
wounds, humane character, from re- 
duced caliber bullets, 230 
Clothing, character of perforations of, 

a medico-legal question, 431 
Colt's automatic pistol, Table No. 3, 
72, 73 
revolver, Table No. 3, 72, 73 
Contusion, by gunshot, of bones, 365 
of bones of leg, 396 
treatment of, 396 
Cord, spinal, concussion of, by large and 
small caliber bullets, 216 
contusion of, 217 
prognosis of g. s. injury of, 224 
symptoms of, following g. s. injury 

of, 222 
treatment in g. s. injury of, 225 
varying lesions of, by reduced caliber 
bullets, 216 
Cranium, wounds of, in Civil War, 167 
fracture in (see Skull), 168 
treatment of, in European War, 194 
Cushing, Harvey, on operations for 
cranio-cerebral wounds in mod- 
ern warfare, 195 



D 



Delorme, E., on the character of the 
bony lesions of the spine by the 
new armament, 216 

Delvigne, Capt., French Army, con- 
cavity in base lead bullet, 5 

Desarlo, Capt. Eugenio, Italian Army, 
laparotomy in Italian-Turkish 
War, 267 

Detectors and extractors, 160 

Diaphyses of long bones, g. s. injuries 
of, 365 



INDEX 



451 



Doebellin's case of g. s. injury by 
pointed or " spitz" bullet, 58 

Doepner, wounds by Mobert rifle, 113 

Douglas, Richard, mortality in ab- 
dominal wounds after lapa- 
rotomy, 263 

Dorst, on predisposition to tetanus in 
wounds with hematoma, 125 

Dudgeon, on bacterial flora of war 
wounds, 129 

Dujardin-Beaumetz, on the value of 
experiments by firing into cada- 
vers, 43 

Dumdum bullet controversy in the 
present European War, 63 



E 



Elbow-joint, wounds, 333 

Enderlen and Sauerbruch in advocacy 

of early laparotomy in present 

European War, 274 
Explosive effects of bullets from hand 

weapons, 37 
Explosives, 11 

"Eupad," as antiseptic gas, 147 
Eusol, as antiseptic gas, 147 

F 

Fauntleroy, M. A., Surgeon U. S. N., 

Report on European War, 19 
Fauntleroy, P. C, M. C, U. S. A., 
abdominal wounds in the Turko- 
Balkan War, 273 
effects of the pointed bullet in Turko- 

Balkan War, 1912-13, 64 
the ratio of shrapnel wounds in the 
Turko-Balkan War, 108 
Femur, g. s. injuries of shaft of, 389 
g. s. contusion of, 389 
g. s. fractures, treatment of, by con- 
servation, 390 
by amputation, 394 
Fenner, Dr. E. D., laparotomy in 
Charity Hospital, New Orleans, 
270 
mortality of abdominal wounds after 
operation, 263 



Firearms, 2 

distance of weapon when discharged, 

a medico-legal question, 427 
how long since weapon was dis- 
charged, a medico-legal question, 
438 
First-aid package, components of, 139 
Fischer, location of heart wounds, 243 
Fish, Dr. B. F. N., on powder-brand, a 

medico-legal question, 427 
Flash from firearms, identity of the 
individual by, a medico-legal 
question, 437 
Fleming, Alexander, bacteriology of 
septic wounds, 369 
phases of inflammation in a septic 
gunshot fracture, 364 
Flint-lock, 4 

Follenfant, laparotomy in Manchurian 
campaign, 265 
malignant pustule in Russo-J apanese 

War, 135 
on the frequency of primary hemor- 
rhage in the Russo-Japanese 
War, 120 
shrapnel wounds in the Russo- 
Japanese War, 108 
wounds of air passages in Manchurian 
campaign, 211 
Food and stimulants, administration 

of, 144 
Foot, g. s. wounds of, 404 
Fore-arm, fractures of, 381 

treatment of fractures of, by con- 
servation, 384 
by amputation, 386 
Foreign bodies, carried into wounds, 

54 
Fractures, compound, treatment of, in 
present European War, 370 
by hypertonic solutions when in- 
fected, 371 
by hypochlorous acid, 371 
treatment at base hospitals, 372 
by plating, in military practice, 
373 
simple and compound, 368 
Fulminate powders, 12 



452 



INDEX 



G 



Gall-bladder, wounds of, 288 
Gangrene, emphysematous, foudroy- 

ante, or traumatic, 157 
Gardner and Bawtree, on bacteriology 

of g. s. wounds, 129 
Genital organs, external, wounds of, 

297 
Girard, General, M.C., U. S. A., on g. s. 
wound of head by Krag-Jorgen- 
sen bullet, 184 
Gray, Col. H. M. W., R. A. M. C., on 
the use of salt sacks in infected 
wounds, 150 
on excision of devitalized tissues in 

infected wounds, 151, 328 
on g. s. wounds of the knee, 357 
Grenades, hand and rifle, 19 
Gun, flint-lock, 4 
hand, 3 
matchlock, 4 
machine, used in U. S. Army and 

European War, 2 
percussion cap, 4 
snaphaunce, 4 
wheel-lock, 4 
Gun-powder, 11 
Guns, large, 2 

Gunshot fractures of cranium, treat- 
ment of, 192 
wounds of spine, 214 
of head, face and neck, 155 
after treatment of, 163 
exploration of, 159 
ratio of, 165 
remote treatment of, 162 



Head, injuries of (see Skull), 165 
wounds of, by reduced caliber bullets, 
57 
brain, abscess in, 192 
concussion, compression and hem- 
orrhage, 190 
hernia cerebri in, 191 
operations for g. s. of , 196 
remote effects of, 190 
Heart and pericardium, g. s. wounds 

of, 422 
Hemorrhage, arrest of, 136, 160 
as a symptom of g. s. wounds, 119 
external primary, 119 
internal primary, 121 
recurrent, 121 
secondary, 161 
Hernia cerebri, 191 
Hip-joint, wounds of, 340 
Hoff, John Van R., Col. M. C, U. S. A., 
on abdominal wounds in the 
Manchurian campaign, 266 
case of Corporal Linn, 348 
Holmes, Gordon, and Percy Sargent, 
treatment of cranial injuries in 
European War, 194 
Howitzers, 2 

Hull, Alfred J., R. A. M. C, on use of 
adrenalin mixture to arrest hem- 
orrhage, 197 
Humerus, g. s. fractures of, 396 
treatment by amputation, 379 
conservation, 377 
Hydraulic theory of " explosive effects," 

93 
Hypochlorous acid gas as an antiseptic, 
146 



H 



Hall, Dr. J. N., on evidence of burn on Immobilization, its value in all g. s. 



clothing, a medico-legal question, 
428 

Hand, g. s. wounds of, 386 

Hand weapons, 3 

Havard, Valery, Col. M. C, abdominal 
wounds in the Manchurian cam- 
paign, 265 



wounds, 140 
Infection in g. s. wounds, 123 

by modern armament, 130 
constitutional and local resistance 

to, 133 
influenced by sectional area of 

projectile, 132 



INDEX 



453 



Infection, in gunshot wounds, prophy- 
laxis of, 138 
source of, 131 

virulence of microorganisms in, 
123 
measures used to prevent infection 
of, 144 
by modern armament, 130 
Intestine, large, wounds of, 283 
Iodine, tincture of, in wound treatment, 
139 



Joints, g. s. wounds of, 319 
amputation in, 326 
ankle, 360 

classification of lesions of, 321 
conservative treatment in, 326 
elbow, wounds of, 333 
Hickson, Col. S. R. A. M. C, on, 

362 
hip-joint, 340 
humane effects of new armament in 

injuries of, 319 
knee, 350 
percentage of mortality in joint 

wounds in five wars, 320 
primary excision in, 327 
shoulder- joint, 329 
suppuration in, 328 
symptoms of wounds of, 325 
treatment of, 326 
vibration synovitis in, from new 

armament, 321 
wrist, 327 

K 

Kidney, wounds of, 293 
Killed to wounded, ratio of, 412 
Knee-joint, wounds of, 350 
Krag-Jorgensen rifle, 6 



Lake, N.C., plating of compound frac- 
tures in military practice, 373 

Laminectomy in g. s. injuries of the 
spine, 226 



Laparotomy, contraindications and 
indications for operation, 281, 
282 
for g. s. wounds, 282 

Lead bullets, pellets, etc., chemical 
analysis of, a medico-legal ques- 
tion, 437 

Leg, g. s. fracture of, 396 

Lissak, Ormond M., Lt. Col., Ordnance 
Dept., on ammunition supply of 
field guns, 18 

Liver, wounds of, 288 

Lowitch, on the influence of hematoma 
in the development of tetanus, 
125 

Luger's automatic pistol, Table No. 3, 
72, 73 

Lynch, Chas., Major, M. C, U.S.A., 
on laparotomy for g. s. wounds 
in the Manchurian campaign, 
264 
stopping-power of Japanese bul- 
let in Russo-Japanese War, 68 
the wounds by shrapnel balls 
in the Russo-Japanese War, 
103 



M 



Machine guns used in European and 
U. S. Armies, 2 

Magazine breech-loading rifles with 
reduced caliber, 6 

Makins, Mr., on the difficulties attend- 
ing abdominal work in military 
practice, 264 
on gunshot wounds of the head in 
the Boer War, 170 

Malignant pustule, in Russo-Japanese 
War, by Follenfant, 135 

Manteuffel, gunshot wounds of the 
heart, 243 

Matas, Dr. Rudolph, statistics of 
Charity Hospital, New Or- 
leans, La., in g. s. wounds of 
abdomen, 269 

Match-lock, 3 

Maxim machine gun, 3 



454 



INDEX 



McAndrew, Patrick H., Major, M. C, 
U. S. A., on the stopping-power 
of U. S. A. service rifle, 69 

Medico-legal phases of g. s. wounds, 425 

Meyer, Dr. Emil, case of g. s. wounds of 
larynx, 212 

Mines and torpedoes, 19 

Minie, Captain, French Army, 5 

Minie's rifle, 5 

Mortars, 2 

Multiple wounds by reduced caliber 
bullets, 427 

Musket, Percussion, 4 



N 



Neck, wounds of, 203 

air passages, 211 

character of, in Civil War, 207 

complications of, 206 

hemorrhage in, 206 

jugular veins, 207 

wounds of nerves, 208 
Nerves, complete division of individual 
nerves, 316 

concussion of individual, 314 

contusion of individual, 315 

partial division of individual 
nerves, 316 

peripheral injuries to, operation for 
secondary involvement in, 318 

treatment of, 317 



O 



CEttingen, wounds of air passages in 
Manchurian campaign, 212 



Pain, as a symptom of g. s. wound, 116 

Pancreas, wounds of, 291 

Parker, Dr. W. E., on fatality of ab- 
dominal wounds, 263 

Penis, wounds of, 297 

Pistol, Colt's automatic, 10 

Poisoned wounds, 134 

the character of toxic substances 
on the implements of war, 134 



Poisoning from powder gases on board 

naval ships, Stokes, 98 
Powder-brand, a medico-legal question, 

427 
Powder-burn, tattoo or stain on cloth- 
ing, a medico-legal question, 
429 
Powder-marks or tattoo, a medico- 
legal question, 429 
Probe, Nelaton, 160 
Projectile, was it jacketed or not, a 

medico-legal question, 438 
Projectiles, 14 

characteristic of lesions caused by, 34 

classification of, 14 

density of, 30 

form of, 30 

from air guns and Flobert rifles, 16 

from Gatling and automatic machine 

guns, 23 
from hand weapons, 14 
from shotguns, 15 

a medico-legal question, 430 
from toy-pistols, 16 
motions of, 27 
translation of, 24 
Propellant, compressed atmospheric 
air as, 14 



Q 



Quenu, on laparotomy in 
European War, 275 



R 



present 



Rectum, wounds of, 287 

Regimental losses in battle, 418 

Revolvers and pistols, 10 

Reyher, Carl, on antiseptics in military 
surgery, 354 

Richardson, on the average mortality 
from abdominal wounds in 
Charity Hospital, New Orleans, 
before the days of laparotomy, 
369 

Rifles, automatic, 33 
breech-loading, 6 



INDEX 



455 



Rifles, Flobert, 11 
Krag-Jorgensen, 6 
Lee-Speed and Lebel, 6 
magazine breech loaders with reduced 

caliber, 6 
Maynard, 6 
military, 3, 6 

evolution of, 4 
Minie, principal features of, 5 
of different combatant armies in 

recent wars, 52 
Sharp, 6 
Spencer, 6 
Springfield, 6 
target, 11 

U. S., caliber .30 model, 1903, 31 
ammunition of 1906 for, 31 
Roosevelt, Colonel Theodore, on the 
effects of the pointed bullet, in 
" African Game Trails," 59 
Rotation of bullets, 27 



S 



Salt sacks, used in wounds as recom- 
mended by Colonel Gray, 150 

Saline solutions in the treatment of 
infected wounds, 148 

Sargent, Percy, and Gordon Holmes, 
management of cranial injuries in 
present European War, 194 

Sauerbruch and Enderlen advocates of 
early laparotomy in present 
European War, 274 

Scrotum, wounds of, 299 

Seaman, Dr. Louis Livingston, on 
traumatic aneurysm in Man- 
churian campaign, 306 

Senn, Dr. Nicholas, hydrogen gas test 
in intestinal wounds, 260 

Septic bullets and septic powders, 132 

Shands, Dr. D. R., statistics of operated 
and non-operated cases of ab- 
dominal wounds in Charity Hos- 
pital, New Orleans, 270 

Shell, for cannon, 16 

common, wounds by, 96 
high-explosive, 16 



Shell, pom-pom, 16 
wounds by, 103 
with case shot, canister or shrapnel, 
wounds by, 103 
Shock, local and constitutional as 
symptoms of g. s. wounds, 117 
treatment of, 137 
Shotgun, 10 
Shotguns, wounds by, a medico-legal 

question, 430 
Shoulder-joint, wounds of, 329 
Shrapnel, common, 18 

high explosive, 18 
Siegel, Dr. Ernest, death rate in ab- 
dominal wounds subjected to 
operation, 263 
Sigmoid flexure, wounds of, 287 
Skull, contusion, 167 

fracture of, with brain injury, 168 
without lesion of cranial contents, 
166 
fracture of inner table alone, 168 
gutter fractures, 170 
outer table alone, 167 
penetrating fractures, 178 
removal of lodged missiles in, 198 
wounds showing explosive effects, 179 
Small arms, evolution of, Table No. 1, 33 
Smith, Lorrain, on the use of "Eusol" 
and "Eupad" in infected wounds 
in the European War, 146 
Smokeless powders, 12 
Spine, wounds of, in Anglo-Boer War, 
214 
in Civil War, 214 
Franco-German War, 214 
injuries of, treatment, 226 
Spleen, wounds of, 292 
Springfield rifle, old, 6 

new, 31 
Stevenson, Col. W. F., R. A. M. C, on 
external primary hemorrhage in 
Boer War, 120 
on g. s. wounds of head, 168 
chest, 230 
Stokes, C. F., surgeon-general U. S. N., 

casualties in naval combat, 98 
Stomach, wounds of, 286 



456 



INDEX 



Stopping power or shock effects of rifle 
bullets in recent wars, 68 
of reduced caliber bullet (Lee-Met- 
ford) in Wizirestan Chitral Ex- 
pedition, 1895, 68 

Strick, on influence of hematoma in the 
development of tetanus, 125 

Symptoms of g. s. wounds, 116 

Synovitis, vibration, from g. s. wounds, 
321 



Tattooing by powder grains, a medico- 
legal question, 429 
Testicles, wounds of, 299 
Tetanus, its treatment, 154 
toy-pistol, 125 
and toy-pistol tetanus, 125 
tendency to, augmented by the 
presence of hematomata in 
wounds, 125 
Thirst as a symptom of g. s. wounds, 

122 
Thompson, Col. John T., Ordnance 
Department, U. S. A., on stop- 
ping-power of pistols and revol- 
vers, 69 
Tibia and fibula, g. s. fractures of, 
396 
treatment by amputation, 401 
by conservation, 397 
Torpedoes, 19 
Toxic substances, vegetable, animal 

and mineral, 134 
Toy-pistol, 16 
tetanus, its source experimentally 
considered, 125 
Trajectory of projectiles, 29 
danger space of, etc., 29 
of different kinds of rifles, 29 
Treatment of g. s. wounds, 136 

administration of food and stimu- 
lants, their great value in, 144 
remote treatment, 162 
Tuffier, T., laparotomy in the French 
Army in the early part of the 
European War, 274 



U 



United States rifle (latest model), 31 
Urethra, wounds of, 298 



Varicose aneurysm, 310 

Velocities and energies of certain 

bullets, Table No. 2, 36, No. 3, 

72, 73 
Virulent infections, treatment of, 154 



W 



Wads and wadding, a medico-legal 

question, 430 
Wallace, C, on laparotomy in present 

European War, 275 
Wheel-lock gun, 3 

White, Dr. C. S., in case of Norman 
Harris, a medico-legal question, 
429 
Wind contusion, 98 

Winter, Col. F. A., M. C, U. S. A., on 
stopping power of the U. S. 
Army service rifle, 69 
Wright, Sir A. E., on the use of saline 
solutions in infected wounds in 
the present European War, 148 
Wrist, wounds of, 337 
Wounds, accidental, suicidal or homi- 
cidal? Medico-legal questions, 
345 
after-treatment of, 163 
by air-gun projectiles, 114 
by firearms, diagnosis of, a medico- 
legal question, 245 
by hand weapons, 34 
by military rifles in recent wars, 

52 
by projectiles from artillery arm, 96 
dangerous to life? A medico-legal 

question, 432 
entrance and exit of, by large caliber 
bullets, 34 
by small caliber bullets, 53 
exploration of, 159 



INDEX 



457 



Wounds, fatality of, percentage in mili- 
tary hospitals, 418 
foreign bodies carried into, 54 
from Flobert rifles, 112 

grenades, bombs, and mines, 109 
pistols and revolvers and their 
shock effects experimentally 
considered, 69 
their lesions, 69 
from reduced caliber bullets in 
Spanish-American War, com- 
pared to those inflicted on the 
cadaver, 42 
from shotgun, 111 

a medico-legal question, 430 
from target rifles, 112 

toy-pistols, 110 
gravity of, by different weapons, 417 
gunshot, definition of, 1 

how was it inflicted, a medico- 
legal question, 434 
infection in, liability of practitioner 
in, a medico-legal question, 433 
inflicted before or after death, a 
medico-legal question, 431 



Wounds, by military rifle and artillery 
fire, percentage of, 413 
multiple, a medico-legal question, 427 
of entrance, a medico-legal question, 

425 
of head by reduced caliber bullets, 57 
of right and left side of body, 418 
open treatment of, 151 
regimental losses by, 415 
regional distribution of, 415 
self-inflicted, non-fatal, a medico- 
legal question, 437 
septic, treatment of, 144 

treatment of, by saline solutions, 
148 
the one causing death, a medico- 
legal question, 432 



X 



X-ray apparatus, field, with motor- 
cycle engine, 443 
best type for use in campaign, 440 
use of, in campaign, 440 
with marine engine, 443 






SEP -° 



_n 19 M 



; a>N 




■ I 






■ 

■ 



■ 



/■'.'v.* 




^m 



